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RC46  .L81  1901       A  manual  of  the  prac 


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http://www.archive.org/details/manualofpracticeOOIock 


A  MANUAL 


OF  THE 


PRACTICE  OF  MEDICINE 


BY 

GEORGE   ROE   LOCKWOOD,  M.D, 

Attending  Physician  to  Bellevue  Hospital,  New  York 


SECOND  EDITION,  REVISED 
WITH   J03  ILLUSTRATIONS,  MANY  OF  THEM  ESf  COLORS 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS    &    COMPANY 

1901 


Copyright,  1901,  by 
W.    B.   SAUNDERS  &  COMPANY. 


ELECTHOTVPEO    BY  PRESS  OF 

WESTCOTT    &    THOMSON.   PHILAOA.  W-   B.   SAUNDERS  &  COMPANY. 


TO 

HORACE    DENNETT 
AS   A   TOKEN    OF    RESPECT   AND    AFFECTION 

THIS    BOOK    IS    RESPECTFULLY    DEDICATED 
BY 

THE   AUTHOR 


PREFACE  TO  THE  SECOND  EDITION. 


In  preparing  this  edition,  the  entire  book  has  been  sub- 
jected to  a  thorough  revision.  Many  portions  have  been 
entirely  rewritten,  and  a  number  of  new  subjects  have  been 
introduced. 

Among  the  new  sections  may  be  mentioned  Bubonic 
Plague,  Gastroptosis,  Gastric  Analysis,  and  Reichmann's 
Disease.  The  subject  of  Malaria  has  been  entirely  re- 
written. The  section  on  Diseases  of  the  Digestive  System 
also  has  been  largely  rewritten,  especially  the  following 
subjects :  Gastritis ;  Dilatation  of  the  Stomach  ;  Gastric 
Atony;  Ulcer  of  the  Stomach;  Gastric  Neuroses;  Enteritis; 
Colitis,  etc. 

Throughout    the    book,   wherever  it    seemed   necessary, 

new  matter  has  been  added,  to  bring  the  subject  down  to 

date. 

5 


PREFACE. 


It  has  been  the  aim  of  the  author  to  present  in  this 
manual  the  essential  facts  and  principles  of  the  practice  of 
medicine  in  a  concise  and  available  form.  It  is  hoped  that 
the  work  will  meet  the  requirements  of  those  who  hereto- 
fore have  been  obliged  to  resort  to  the  larger  works  of  refer- 
ence with  which  medical  literature  is  so  v/ell  supplied. 

In  the  arrangement  of  the  subject-matter  the  admirable 
classification  of  Osier  has  been  adopted  with  but  a  few  un- 
important modifications. 

Acknowledgment  of  the  author's  indebtedness  is  hereby 
made  to  those  writers  from  whose  articles  illustrations  have 
been  taken  for  use  in  this  manual,  credit  in  each  case  being 
given  in  the  text.  The  author  also  desires  to  extend  his 
thanks  to  Mr.  Thomas  F.  Dagney,  of  Mr.  Saunders'  publi- 
cation rooms,  for  the  preparation  of  the  index  and  for  valu- 
able suggestions  of  a  varied  character  while  the  manual 
was  going  through  the  press. 


CONTENTS. 


I.  THE  INFECTIOUS  DISEASES. 

PAGE 

Typhoid  Fever 17 

Typhus  Fever 43 

Relapsing  Fever 48 

Small-pox       51 

Vaccinia 59 

Varicella 60 

Scarlet  Fever 61 

Measles       70 

Rubella      • 74 

Ei^idemic  Parotitis 76 

Whooping-cough       78 

Epidemic  Influenza 81 

Dengue      85 

Epidemic  Cerebro-spinal  Meningitis 87 

Diphtheria 93 

Erysipelas      106 

Pysemia       Ill 

SepticEemia .    .  II3 

Cholera 1 15 

Yellow  Fever 120 

Syphilis 124 

Acquired  Syphilis 125 

Hereditary  Syphilis      131 

Acute  Miliary  Tuberculosis 133 

Malarial  Fever 138 

Anthrax 15 1 

Hydrophobia 153 

Tetanus      156 

Leprosy •    .  160 

Glanders 162 

Actinomycosis 164 

Milk  Sickness 166 

Weil's  Disease 167 

Bubonic  Plague 167 


II.  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

Diseases  of  the  Pericardium 169 

Pericarditis 169 

Purulent  Pericarditis 177 

Chronic  Adhesive  Pericarditis 178 

Tubercular  Pericarditis 179 

Cancerous  Pericarditis      . 180 

Hydropericardium 181 

Hffimopericardium 181 

Pneumopericardium 181 

9 


lO  CONTENTS. 

PAG1-: 

2.  Diseases  of  the  Heart 182 

llypertropliy  and  Dilatation 182 

•  Hyperiropliy 1S6 

Dilatation       189 

Acute  Eniiocaaluis 196 

Maliijnant  Endocarditis 200 

Ciironic  Endocarditis 204 

Atheroma 206 

Mitral  Incompetency 207 

Mitral  Stenosis 2IO 

Aortic  Kegurtjitation 214 

Aortic  Stenosis 218 

Tricuspid  Regurgitation 220 

Tricuspid  Stenosis         221 

Pulmonary  Regurgitation 221 

Pulmonary  Stenosis 222 

3.  Diseases  of  the  Myocardium      227 

Acute  Myocarditis 227 

Chronic  Myocarditis ....  228 

Syphilitic  Slyocarditis 230 

Degeneration  of  the  Myocardium 230 

Aneurysm  of  the  Heart 236 

Rupture  of  the  Heart 237 

4.  Neuroses  of  the  Heart .' 238 

Palpitation 238 

Tremor  Cordis 239 

Intermittent  Action 239 

Tachycardia       240 

Brachycardia 241 

Angina  Pectoris 242 

Pseudo-angina 245 

Exophthalmic  Goitre 246 

5.  Congenital  Malformations 250 

6.  Diseases  of  the  Arteries 252 

Arterio-sclerosis 252 

Syphilitic  Arteritis 255 

Aneurysm       256 

Aneurysm  of  the  Abdominal  Aorta    ......        263 


III.   DISEASES  OF   THE  RESPIRATORY  SYSTEM. 

Diseases  of  the  Lnr\-nx      265 

Spasm  of  the  Larynx 265 

Acute  Catarrhal  Laryngitis 267 

Chronic  Catarrhal  Laryngitis 269 

Membranous  Laryngitis 270 

Tubercular  Laryngitis 271 

Syphilitic  Laryngitis 272 

CEdematous  Laryngitis 273 

Diseases  of  the  lironchi 274 

Acute  Catarrhal  Bronchitis 274 

Acute  Croupous  Bronchitis      278 

Chronic  Catarrhal  Bronchitis 279 

Chronic  Croupous  Bronchitis 281 

Bronchiectasis 281 

Asthma 283 

Diseases  of  the  Lungs 288 

Circulatory  Disturbances 288 


CONTENTS.  1 1 

PAOE 

Congestion  of  the  Lungs 288 

Qiclema  of  the  Lungs 289 

Puhnonary  Hemorrhage 290 

Bronclio-pulmonary  Hemorrhage,  or  Hsemoplysis     .    ,    .    .  290 

Pulmonory  Apoplexy 293 


Lobar  Pneumonia 


294 

Bronclio-pneumonia ^og 

Broncho-pneumonia  in  Adults tj- 

Interstitial  Pneumonia ti^ 

Interlobular  Emphysema ^21 

Vesicular  Emphysema 921 

Gangrene  of  the  Lung ^26 

Aljscess  of  the  Lung -728 

Syphilis  of  the  Lung ^29 

New  Growths  of  the  Lung ,,0 

Echinococcus  Cysts  of  the  Lung 0^2 

Tubercular  Liflammations  in  General ^^2 

Tubercular  Diseases  of  the  Lung ,,5 

Acute  Pulmonary  Tuberculosis T^y 

Chronic  Pulmonary  Tuberculosis -s.q 

Acute  Pulmonary  Phthisis -^.a 

Chronic  Pulmonary  Phthisis ^_^g 

Diseases  of  the  Pleura o5o 

Fibrinous  or  Dry  Pleurisy ^go 

Pleurisy  with  Effusion -152 

Purulent  Pleurisy t^q 

Chronic   Pleurisy oy^ 

Tubercular  Pleurisy ^y5 

Pneumothorax       ,yy 

New  Growths  of  the  Pleura ,gj 

Hydrothorax •,82 

Haemothorax 

Diseases  of  the  Mediastinum 


382 

Lymphadenitis •  .     ,gT 

384 
386 


Mediastinal  Tumors 
Abscess  of  the  Mediastinum 


Emphysema  of  the  Mediastinum ,§5 

Mediastinal   Hsematoma ,gy 

Diseases  of  the  Thymus  Gland .jgy 

IV.   DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

1.  Diseases  of  the  CEsophagus •  388 

Acute  CEsophagitis 388 

Chronic  CEsophagitis 389 

Stenosis  of  the  CEsophagus 389 

Cicatricial  Stenosis 389 

Cancerous  Stricture 391 

Spasmodic  Stenosis 392 

Dilatations  and  Diverticula 393 

Paralysis  of  the  CEsophagus 394 

Rupture  of  the  CEsophagus 394 

Varix  of  the  CEsophagus  , 394 

2.  Diseases  of  the  Stomach 395 

Acute  Catarrhal  Gastritis 395 

Toxic  Gastritis 397 

Acute  Croupous  Gastritis 398 

Acute  Suppurative  Gastritis 398 


1 2  COXTEXTS. 

PACE 

Mycotic  and  Parasitic  Gaslriiis 399 

Chronic  Catarrhal  Gastritis 399 

Atony 407 

l)ilatation  of  the  Sioniacli ;  Gastrectasis 411 

L'icer  of  the  Stomach 416 

Cancer  of  the  Stomach        424 

Non.cancerous  Tumors  of  the  Stomach 431 

(iastroptosis 43' 

Hemorrhage  from  the  Stomach 433 

Gastric  Nemoses 43'' 

Sensory  Neuroses 43/ 

Secretory  Neuroses 439 

Motor  Neuroses 44^ 

3.  Diseases  of  tlie  Intestines 442 

Morning  Diairhrea 442 

Acute  Catarriial  Enteritis 443 

Clnonic  Catarrhal  Enteritis 445 

Plilegnionous  Enteritis 447 

I'seuilomenibranous  Enteritis 44^ 

Mucous  Cohtis 44S 

Diarrhieal  Diseases  of  Ciiildren 450 

Acute  Dyspeptic  Diarrhcea 451 

Acute  Entero-coHtis 451 

Cholera  Infantum 453 

Cholera  Morbus 456 

Colitis 457 

Acute  Catarrhal  Colitis 45S 

Tropical  or  Amoebic  Colitis ...  459 

Acute  Croupous  Colitis 461 

Ciironic  Colitis  and  Chronic  Dysenteiy 463 

Appendicitis 465 

.-\cute  Catarrhal  Appendicitis 465 

Acute  Suppurative  Appendicitis  467 

Gangrenous  Appendicitis 471 

Chronic  A]i]iendicitis 473 

Ulceration  of  the  Intestine 474 

Cancer  of  the  Intestine 479 

Cancer  of  the  Rectum 480 

Cancer  of  the  Caput  Coli 481 

Cancer  of  the  Duodenum 482 

Non-cancerous  Tumors  of  the  Intestine 482 

Intestinal  Obstruction 482 

Hemorrhage  from  the  Intestine 487 

Fecal  Accumulation 489 

Amyloid  Degeneration  of  the  Intestine 492 

4.  Diseases  of  the  Peritoneum 492 

Acute  Peritonitis 492 

Acute  Peritoneal  Sepsis 493 

Acute  Diftuse  Peritonitis 494 

Acute  Circumscribed  Peritonitis 497 

Chronic  Peritonitis 499 

Chronic  Hemorrhagic  Peritonitis 501 

Tul^eicular  Inflammations  of  the  Peritoneum 502 

Acute  Tul>erculosis  of  the  Peritoneum 502 

Acute  Tubercular  Peritonitis 502 

Chronic  Tubercular  Peritonitis 504 

Cancer  of  the  Peritoneum ; 505 

Ascites 307 

5.  Diseases  of  the  Liver 510 


CONTENTS.  13 

PAGE 

Functional  Disturbances  of  the  Liver ^10 

Circulatory  Disturbances  of  the  Liver 512 

Diseases  of  the  Capsule  of  the  Liver 513 

Acute  Perihepatitis  ^ 513 

Chronic  Fibrinous  Perihepatitis 514 

Syphilitic  Perihepatitis      515 

Acute  Parenchymatous  Hepatitis 515 

Cirrhosis  of  the  Liver 517 

Atrophic  Cirrhosis 517 

Hypertrophic  Cirrhosis 522 

Syphilitic  Cirrhosis 1523 

Abscess  of  the  Liver 525 

Tubercular  Disease  of  the  Liver •  530 

Nev^r  Growths  of  the  Liver 530 

Hydatid  of  the  Liver 534 

Fatty  Liver 536 

Amyloid  Liver 538 

Jaundice 539 

Acute  Febrile  Jaundice 542 

Catarrhal  Jaundice 542 

Cholelithiasis 543 

Cancer  of  the  Gall-ducts 551 

Diseases  of  the  Blood-vessels  of  the  Liver 551 

Diseases  of  the  Pancreas 553 

Hemorrhage 553 

Acute  Hemorrhagic  Pancreatitis 553 

Gangrenous  Pancreatitis 555 

Suppurative  Pancreatitis 555 

Chronic  Pancreatitis 555 

Pancreatic  Cysts 555 

Cancer  of  the  Pancreas    .    .    .   '. 557 

V.  DISEASES  OF  THE  KIDNEY. 

Congenital  Malformations  of  the  Kidneys 559 

Movable  Kidney 559 

Anomalies  of  the  Urinary  Secretion 561 

Albuminuria      561 

Hsematuria 5^4 

Hsemoglobinuria 565 

Pyuria , 567 

Peptonuria 567 

Phosphaturia S^'^ 

Lithsemia ;  Uricsemia 568 

Oxaluria 569 

Chyluria 570 

Indicanuria 570 

Glycosuria 57° 

Lipuria 57° 

Acetonuria ^Ti- 

Acute  Congestion  of  the  Kidneys 571 

Chronic  Congestion  of  the  Kidneys , 57I 

Acute  Degeneration  of  the  Kidneys  . 572 

Chronic  Degeneration  of  the  Kidneys 573 

Acute  Exudative  Nephritis 574 

Acute  Diffuse  Nephritis 57^ 

Chronic  Bright's  Disease 579 

Chronic  Diffuse  Nephritis  with  Exudation 579 

Chronic  Diffuse  Nephritis  without  Exudation 583 


14  co.vr/^xjs. 

PAGE 

Waxy  Dcijeneration  of  ihe  Kiilney 589 

Tubercular  Diseases  of  the  Kidney 590 

Tuberculosis  of  the  Kidney 590 

Tubercular  ryelunephritis 590 

Suppurative  Disease  of  the  Kidney 592 

Tumors  of  the  Kidney 595 

Cysts  of  the  Kidney 597 

P}elitis 59S 

Hydronephrosis 599 

Nephrolithiasis 600 

Perinephritic  Abscess 606 

VI.   CONSTITUTIONAL  DISEASES. 

Acute  Articular  Rheumatism 607 

Pseudo-Rheumatism 614 

Chronic  Anicular  Ulieumalism 614 

Muscular  Rheumatism 616 

Gout      617 

Arthritis  Deformans 624 

Diabetes  Mellitus 627 

Glycosuria 633 

Diabetes  Insipidus 634 

ScuTvy 635 

Rickets       63S 

Purpuric  Diseases 640 

Symptomatic  Purpura 641 

Purpura  Rheumatica 642 

Purpura  Hemorrhagica 642 

Haemophilia       645 

VII.   DISEASES  OF  THE  BLOOD  AND  THE  LYMPHATIC 

GLANDS. 

Anamia 647 

.Secondary  Anoemia 647 

Chlorosis 650 

Pernicious  Anaemia 652 

Leucocytosis 655 

Leukaemia 656 

Pseudo-leukaemia      660 

Addison's  Disease 664 

Tuberculosis  of  the  Lymph-glands 666 


VIII.  DISEASES  OF  THE  NERVOUS  SYSTEM. 

I.  Diseases  of  the  xMembranes  of  the  Brain 668 

(a)  Diseases  of  the  Dura  Mater 668 

Acute  External  Pachymeningitis 668 

Acute  Internal  Pachymeningitis      668 

Chronic  Internal  Pachymeningitis 669 

Syphilitic  Pachymeningitis  .    .    .    ,  ' 670 

(d)  Diseases  of  the  Pia  Mater 670 

Tubercular  Meningitis 670 

Acute  Non-tubercular  Meningitis 673 

Syphilitic  Meningitis 675 

Chronic  Meningitis 675 


CONJ'EN'J'S. 


PAGI-; 


Meningeal  Hemorrhage 676 

2.  Diseases  of  tlie  Blood-vessels  of  the  Brain 678 

Congestion 678 

Anremia     .    .    .    .    ^ 679 

Qidema      57^ 

Cerel:)ral  Hemorrhage 679 

Embolism  of  the  Cerebral  Arteries 684 

Thrombosis  of  the  Cerebral  Arteries 687 

Aneurysm  of  the  Cerebral  Arteries 687 

Thrombosis  of  the  Venous  Sinuses 689 

Cerebral  Endarteritis goo 

3.  Diseases  of  the  Brain-substance ,  692 

Cerebral  Localization 692 

Abscess  of  the  Brain 697 

Tumors  of  the  Brain 699 

Cerebral  Atrophy  in  Children 704 

Cerebro-spinal  Sclerosis 707 

General  Paresis 708 

Chronic  Hydrocephalus 710 

Syphilis  of  the  Brain 711 

4.  Diseases  of  the  Spinal  Cord 714 

(fl)  Affections  of  the  Meninges 714 

Diseases  of  the  Dura  Mater 714 

Diseases  of  the  Pia  Mater 715 

Acute  Leptomeningitis 71c 

Chronic  Leptomenmgitis 717 

Hemorrhage  into  the  Spinal  Membranes •  718 

(J>)  Diseases  of  the  Blood-vessels 71^ 

Anaemia 71^ 

HyperEemia 71^ 

Hemorrhage  into  the  Cord 71^ 

Caisson  Disease 720 

(f)  Diseases  of  the  Substance  of  the  Cord 722 

Acute  Anterior  Poliomyelitis 722 

Anterior  Poliomyelitis  in  Children 722 

Anterior  Poliomyelitis  in  Adults     .    .    .    .    ■. 726 

Subacute  and  Chionic  Poliomyelitis 726 

Progressive  Muscular  Atrophy 727 

Amyotrophic  Lateral  Sclerosis     . 7^0 

Bulbar  Paralysis 7-51 

Ophthalmoplegia       733 

Lateral  Sclerosis 733 

Locomotor  Ataxia 735 

Hereditary  Ataxia 742 

Ataxic  Paraplegia 743 

Myelitis,  Acute  and  Chronic .    .    .  743 

Acute  Ascending  Paralysis 747 

Syringo-myelia 74S 

Compression-myelitis 745 

Tumors  of  the  Spinal  Cord 7c;o 

Brown-Sequard's  Paralysis 7^1 

5.  Diseases  of  the  Cranial  Nerves 7^1 

Olfactory  Nerve 7:;! 

Optic  Nerve 751 

Third  Nerve 7C2 


Fourth  Nei^ve 


753 


Fifth  Nerve 7C3 

Sixth  Nerve 754 

Seventh  Nerve 754 


i6  co.vrAWJ's. 

PAGE 

Auditor)-  Nerve 757 

CIlos'*o-phan,  ngeal  Nerve 759 

l'neuiiu>gastric  Nerve 759 

Spinal  Acccssoiy  Nerve 762 

Hypoj;lossal  Nerve 764 

6.  Diseases  of  the  Periplieral  Nerves 765 

Neuritis      765 

Localized  Neuritis 765 

Multiple  Neuritis 768 

Neuromata 772 

Neuralgia 773 

7.  General  Ncr\ous  Diseases 776 

Infantile  Convulsions 776 

Kpilepsy 778 

I'aialysis  Agitans 784 

Acute  Delirium 786 

Chorea 787 

Choreiform  Affections 793 

Tetany 794 

Migraine 795 

Occupation -neuroses , 797 

Neurasthenia 798 

Hysteria 800 

Sunstroke 807 

Delirium  Tremens 810 

8.  Vaso- motor  and  Trophic  Disorders 811 

Raynaud's  Disease 811 

Acute  Circumscribed  CEdenia 812 

Facial  Hemiatrophy 813 

Myxcedema  and  Cretinism 813 

Scleroderma 815 

Acromegaly 815 


IX.    DISEASES  OF   THE  MUSCLES. 

Myositis 817 

Progressive  Muscular  Dystrophy 817 

Paramyoclonus  Multiplex 819 

Thomsen's  Disease 819 


X.    AXLMAL  PARASITES. 

Trematodes 821 

Nematodes 821 

Ascaris  Lumbricoides 821 

Oxyuris  Vermicularis 822 

Anchylostoma  Duodenale 823 

Trichocephalus  Dispar 823 

Trichina  Spiralis S23 

Filaria  Sanguinis  Hominis 825 

Cestodes 826 

Echinococcus  Disease      827 


A  MANUAL 

OF  THE 

PRACTICE  OF  Medicine. 


L    THE  INFECTIOUS  DISEASES. 


TYPHOID  FEVER. 

Definition  and  Synonyms. — Typhoid  fever  is  an  acute 
infectious  disease  caused  by  a  specific  bacillus,  and  is  cha- 
racterized anatomically  by  lesions  of  the  intestinal  and 
mesenteric  glands  and  by  enlargement  of  the  spleen.  The 
disease  runs  a  febrile  course  of  three  or  four  weeks,  with  a 
characteristic  eruption  and  systemic  symptoms.  Synonyms : 
Typhus  kvev  {German);  Abdominal  typhus;  Ileo-typhus; 
Enteric  fever;  Autumnal  fever. 

Etiology. — Typhoid  fever  is  one  of  the  most  widely 
spread  of  all  the  infectious  fevers ;  it  occurs  in  all  countries 
and  in  all  climates,  though  it  is  more  frequent  in  the  tem- 
perate zones.  It  may  occur  at  any  time  of  the  year,  but  it 
is  most  commonly  seen  in  late  summer  and  in  early  fall, 
hence  the  name  "  autumnal  fever "  which  has  sometimes 
been  applied  to  it.  It  seems  to  occur  with  especial  fre- 
quency after  hot.  dry  summers. 

The  disease  affects  the  sexes  equally,  although  in  hospital 
practice  more  cases  are  met  with  in  men,  because  they  more 
readily  apply  for  hospital  treatment. 

The  disease  may  occur  at  any  age,  but  young  adults 
between  the  ages  of  fifteen  and  twenty-five  are  especially 
susceptible.  After  the  age  of  thirty-five  the  disease  appears 
progressively  infrequent. 

There  is  in  this  disease,  as   in  all   infectious  diseases,  a 
great  difference  in  personal  susceptibility,  some  individuals 
being  more  readily  infected  than  others  who  have  been  sub- 
2  '  17 


1 8  MANUAL    OF   THE   PRACTICE    OE  MEDICLYE. 

jccted  to  the  same  degree  of  exposure.  In  cities  strangers 
are  more  susceptible  to  this  fever  than  old  inhabitants.  The 
development  of  the  disease  after  exposure  is  fa\ored  by  any 
inflammatory  condition  of  the  intestine,  the  entrance  of  the 
germ  into  the  lymphatics  being  favored  b)'  the  epithelial 
desquamation  resulting  from  the  catarrhal  process.  A  low 
and  sickly  condition  of  the  general  health  does  not  seem  to 
increase  the  susceptibility  to  infection.  The  disease  appears 
in  both  epidemic  and  endemic  forms.  The  epidemics  are 
usually  local,  affecting  a  group  of  houses,  an  institution,  or 
a  part  of  a  town.  The  longer  the  epidemic,  the  more  diffi- 
cult it  often  is  to  trace  the  source  of  infection.  It  appears 
as  an  endemic  disease  where  it  had  previously  existed  as  an 
epidemic,  and  it  is  endemic  in  almost  all  large  cities.  The 
source  of  infection  is  with  difficulty  traced  in  endemic  cases. 

The  actual  exciting  cause  of  typhoid  fever  is  now  proved 
to  be  the  infection  of  the  patient  by  a  specific  germ  known 
as  the  bacillus  typhosus,  or  Eberth's  bacillus.  This  germ  is 
a  short,  mobile  bacillus  whose  length  is  equal  to  one-third 
the  diameter  of  a  red  blood-cell,  and  having  rounded  bulbous 
ends  which  often  present  a  shining  appearance,  due  rather 
to  alterations  in  its  protoplasm  than  to  spore-growth,  as  was 
at  first  supposed.  In  its  appearance  and  growth  this  germ 
closely  resembles  the  bacterium  coli  coinvnoic,  or  ordinary 
colon-bacillus,  from  which  it  is  hard  to  differentiate  it.  The 
typhoid  bacillus  grows  with  ease  in  almost  every  kind  of 
nutritive  media,  and  it  possesses  extraordinary  vitality.  It 
may  persist  in  drinking-water  or  in  the  soil  for  weeks  or  for 
months,  and  may  even  increase  in  number.  It  grows  with 
great  rapidity  in  milk  without  altering  its  appearance  or  taste; 
and  so  great  is  its  tenacity  of  life  that  it  ma}^  remain  impris- 
oned in  ice  for  months  without  losing  its  virulent  properties. 
In  the  accumulations  of  privy-vaults  and  sewers  it  finds 
conditions  most  favorable  for  its  growth  and  activity. 
Cultures  are  killed  by  a  temperature  of  60°  C,  by  carbolic 
acid  (l  :  200),  and  by  corrosive-sublimate  solution  (i  :  2500). 
Cultures  resist  drying  for  several  days,  but  the  growth  of  the 
bacilli  is  retarded  by  exposure  to  sunlight. 

The  bacillus  obtains  entrance  to  the  body  through  the 


TYPHOID   FEVER.  1 9 

alimentary  canal,  and  enters  the  intestinal  lymphoid  tissue 
probably  through  abrasions  of  the  epithelial  coat.  It  has 
been  found  in  the  lymphoid  tissue  of  the  intestines,  in  the 
mesenteric  glands,  the  spleen,  the  liver,  at  times  in  the  blood 
taken  from  the  rose  spots,  and  occasionally  in  the  urine.  It 
has  been  found  also  in  some  of  the  complicating  lesions  of 
the  disease.  The  bacilli  are  found  in  clusters  in  the  intes- 
tinal contents  and  the  stools  of  patients,  and  are  thrown  out 
from  the  body  in  this  way.  They  are  not  eliminated  from 
the  lungs  or  the  skin. 

Methods  of  Infection. — The  disease  is  in  no  sense  per- 
sonally contagious,  cases  of  typhoid  being  received  into  the 
general  wards  of  hospitals  without  risk.  The  bacilli  being 
cast  off  only  in  the  dejecta  of  the  patient,  it  is  from  the 
stools  and  urine  that  danger  of  infection  arises.  If  the 
stools  are  thoroughly  disinfected  and  the  bacilli  are  killed, 
there  is  no  further  risk  of  a  spread  of  the  infection.  If  the 
stools  are  not  disinfected,  however,  the  bacilli  will  live  and 
thrive  in  them,  and  this  infected  sewage,  draining  into  water- 
supplies,  will  spread  the  disease  among  those  who  drink  of 
such  water.  It  is  important  also  that  the  urine  should  be 
disinfected  in  like  manner. 

There  are  three  ways  by  which  the  infection  of  typhoid 
may  occur : 

The  first  method  is  by  direct  infection  from  stools  or 
urine.  While  not  common,  infection  has  occurred  among 
attendants  on  the  sick  and  among  those  who  have  washed 
the  soiled  linen  of  typhoid  patients,  the  germs  being  trans- 
ferred from  infected  hands  to  the  food,  and  thus  obtaining 
entrance  to  the  body. 

The  second  method  of  infection  is  by  contamination  of 
the  water-supply.  This  is  the  usual  source  of  infection, 
and  it  explains  the  origin  of  epidemics  of  the  disease  that 
occur  from  time  to  time  in  towns,  in  institutions,  and  in 
villages.  Contamination  of  drinking-water  with  filth  and 
sewage  will  not  produce  the  disease  unless  to  such  sewage 
is  added  the  specific  germ.  Interesting  investigations  of  epi- 
demics frequently  show  their  origin  in  the  contamination  of 
the  water-supply  by  the  dejecta  of  a  single  typhoid  patient. 


20  MAXrAL    OF   THE   PRACTICE    OF  MEDICIXE. 

even  though  months  may  have  elapsed  between  the  infec- 
tion of  the  sewage  and  the  consequent  contamination  of  the 
water-supply.  The  source  of  contamination  is  most  easily 
traced  in  small  epidemics,  and  examples  of  epidemics  in 
hotels,  villages,  and  towns  so  traced  are  to  be  found  reported 
in  full  in  medical  literature.  In  the  same  way  the  infection 
may  be  conveyed  by  impure  ice,  after  the  thawing  of  which 
the  germs  regain  their  vitality. 

The  third  method  of  infection  is  by  food.  The  bacilli 
may  be  conveyed  by  milk,  in  which  they  readily  thrive,  and 
to  which  they  are  added  by  impure  water,  used  either  to 
wash  the  cans  or  to  dilute  the  milk.  A  very  prolific  cause 
for  t)'phoid  fever  in  late  years  has  been  from  the  injection  of 
oysters  that  have  been  placed  in  contaminated  fresh  water 
to  sweeten  them  before  they  are  sent  to  market. 

There  are  reports  of  epidemics  apparently  caused  by  eat- 
ing meat  of  diseased  cattle,  but  this  mode  of  infection  is  not 
yet  definitely  determined.  Poor  drainage,  sewer-gas,  and 
imperfect  hygiene  will  not  of  themselves  cause  the  disease: 
they  only  offer  favorable  conditions  for  the  growth  and 
development  of  the  bacillus. 

Pathology. — The  lesions  are  divided  into  those  essential 
to,  and  those  complicating,  the  disease. 

EssENTi.AL  Lesions. — The  essential  lesions  consist  in — 
I.  Changes  in  the  lymph-glands  of  the  intestine  ;  2.  Changes 
in  the  mesenteric  glands  ;   3.  Enlargement  of  the  spleen. 

I.  The  clianges  in  the  intestinal  lymphoid  tissue  are  seen 
in  both  the  solitary  and  the  agminated  glands,  but  espe- 
cially in  the  latter.  They  are  most  constant  in  Peyer's 
glands  of  the  lower  portion  of  the  ileum,  and  they  may 
appear  here  alone.  In  about  one-third  of  the  cases  the 
glands  of  the  caecum  and  colon  are  affected.  There  are 
rare  cases  in  which  the  intestinal  lesions  are  not  developed. 

Congestion  and  Hyperplasia. — The  first  change  consists 
in  the  congestion  and  swelling  of  the  lymph-follicles,  noticed 
on  the  second  day  of  the  disease.  Toward  the  end  of  the 
first  week  there  is  added  an  increase  in  number  of  the  cell- 
ular elements,  some  cells  resembling  the  ordinary  lymphoid 
cells,  while  others  are  large  and  round  with  several  nuclei. 


TYPHOID   FEVER.  21 

This  hyperplasia  further  increases  the  size  of  the  gland. 
The  cellular  increase  is  not  entirely  confined  to  the  gland, 
but  infiltrates  the  mucous  membrane  in  its  vicinity,  small 
isolated  foci  being  also  seen  in  the  muscular,  the  sub- 
serous, and  even  the  serous  coats  of  the  intestine.  In  these 
.masses  of  lymphoid  cells  the  bacilli  are  constantly  found. 
This  cellular  increase  persists  during  the  second  week  of  the 
disease.  In  very  mild  cases,  the  lesion  goes  no  further  than 
this,  but  resolution  occurs,  the  congestion  disappears,  the 
cells  undergo  fatty  degeneration  and  absorption,  and  the 
gland  assumes  again  its  normal  appearance. 

Necrosis. — In  most  cases,  however,  the  lesion  progresses 
to  such  a  degree  that  resolution  becomes  impossible.  The 
swelling  of  the  gland  presses  on  its  blood-vessels,  and,  cut- 
ting off  its  blood-supply,  induces  a  condition  of  anaemia- 
necrosis,  and  in  consequence  of  this  condition  and  of  the 
direct  action  of  the  bacilli  upon  the  tissues  the  cells  die 
and  are  cast  off,  either  gradually,  by  a  process  of  ulceration, 
or  en  masse,  by  a  process  of  gangrene.  In  either  case  an 
ulcer  is  left,  the  walls  and  floor  of  which  are  composed  of 
infiltrated  glandular  tissue,  and  by  the  further  disintegration 
of  these  infiltrating  cells  the  ulcer  may  increase  in  size  and 
in  depth.  Such  ulceration  may  perforate  through  the  entire 
intestinal  wall,  or  the  separation  of  the  slough  may  be  the 
cause  of  hemorrhage.  The  process  of  ulceration  occupies 
the  third  week  of  the  disease. 

Cicatrisation. — During  the  fourth  week  the  ulcer  begins 
to  cicatrize  and  the  normal  glandular  elements  are  re-formed. 
In  some  cases  an  ulcer  may  cicatrize  in  some  portions  and 
extend  in  others.  Cicatrization  should  be  complete  toward 
the  close  of  the  fourth  week,  but  the  ulcer  may  remain 
sluggish  and  inactive   until  the  sixth  or  the  eighth  week. 

2.  Changes  in  the  mesenteric  glands  are  of  the  same  nature 
and  intensity  as  those  in  the  intestine,  the  only  difference 
being  that  the  products  of  necrosis  cannot  be  thrown  off, 
but  form  foci  of  softened  purulent  matter  containing  bacilli. 
Small  foci  may  eventually  be  absorbed,  while  larger  ones 
may  become  dry  and  cheesy  and   enclosed  by  a  fibrous 


22  MA.VL'AL    OF  THE  PRACTICE    OF  MEDICINE. 

capsule.  At  nn\-  time  a  fresh  focus  ma)'  rupture  into  the 
peritoneal  ca\'it)-. 

3.  TJic  spleen  rec]^ularl\'  becomes  increased  in  size  and 
harder  in  consistency.  These  changes  proceed  until  the 
third  week,  after  which  the  spleen  becomes  soft  and  pulpy 
and  returns  to  its  normal  size.  In  rare  cases  the  spleen 
becomes  soft,  but  does  not  increase  in  size.  Rupture  or 
a  gangrenous  abscess  of  the  spleen  may  occur. 

Complicating  Lesions. — i.  Pcrilonitis. — This  condition 
may  be  caused  in  a  variety  of  ways — either  from  perforation 
of  the  intestine  by  an  ulcer,  from  rupture  of  a  softened  mes- 
enteric gland,  or  from  rupture,  abscess,  or  infarction  of  the 
spleen.  In  some  cases  no  cause  can  be  found  for  the  peri- 
tonitis. 

2.  Catarrhal  or  Croupous  Enteritis. — Severe  inflamma- 
tions are  rare,  though  a  mild  catarrhal  enteritis  is  com- 
monly seen. 

3.  Parotitis. — This  condition  may  occur  during  the  second 
or  third  week,  and  may  proceed  to  the  formation  of  an 
abscess. 

4.  The  liver  becomes  hypersemic  and  increased  in  size. 
The  cells  become  swollen  and  coarsely  granular.  There 
may  be  foci  of  lymphoid  cells  in  the  substance  of  the  organ. 

5.  The  kiihieys  show  parenchymatous  degeneration  of 
the  cells  of  the  convoluted  tubules.  In  rare  cases  there 
may  be  acute  nephritis.  There  may  be  small  foci  of  infil- 
trating lymphoid  cells  which  may  proceed  to  suppuration, 
causing  so-called  "  miliary  abscesses."  In  these  cellular  foci 
Eberth's  bacilli  are  found ;  they  may  be  present  also  in  the 
urine  in  these  cases. 

6.  The  heart-muscle  is  soft  and  flabby  and  may  be  the 
seat  of  waxy  degeneration.  There  may  be  degeneration  of 
any  of  the  voluntary  muscles.  In  rare  cases  pericarditis 
with  efi'usion  of  serum  or  of  pus  is  found. 

7.  The  pharyjix  or  the  larynx  is  often  the  seat  of  a  ca- 
tarrhal or  croupous  inflammation.  QEdema  of  the  glottis 
may  occur,  and  ulceration  of  the  larynx  occurs  in  a  certain 
number  of  cases.  Necrosis  or  sloughing  of  the  cartilages 
may  occur. 


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TYPHOID 

FEVER.                                                                                                                                                                      Plate  3. 

DiKifiB      22      23       24      25      26       27      28      29      30      31       32      33      34      35      36      37       38      39      40       41      42 

43      44       45      46      47      48      49      50      51      52      53      54      55      56      57      58 

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Recrudescences  and  a 


TYPHOID   FEVER.  2  7, 

8.  Lungs. — In  nearly  all  cases  there  is  some  degree  of 
hypostatic  congestion.  In  other  cases  there  is  bronchitis 
with  zones  of  peribronchial  pneumonia.  This  is  a  serious 
lesion.  Mild  degrees  of  bronchitis  are  commonly  seen. 
Gangrene  or  abscess  of  the  lung  may  be  found,  and  pleurisy 
with  effusion  occurs  in  a  small  number  of  the  cases. 

There  may  be  thrombosis  of  some  of  the  larger  veins, 
especially  of  the  femoral ;  less  frequently  there  is  thrombosis 
of  the  cerebral  sinuses. 

Symptoms. — As  the  symptoms  are  so  complex  and  the 
clinical  aspect  of  the  disease  so  varied,  it  seems  best  to  con- 
sider each  symptom  at  first  in  detail,  and  then  to  give  a 
general  description  of  their  clinical  grouping. 

Fever. — In  a  typical  case  the  temperature  should  run  a 
self-limited  course  of  four  weeks'  duration,  each  week  pos- 
sessing characteristics  of  its  own.  During  the  first  week  the 
temperature  gradually  mounts,  higher  in  the  evening  than 
in  the  morning,  and  higher  each  day  than  on  the  day  pre- 
vious. The  maximum,  which  is  reached  by  the  end  of  the 
week,  is  between  103°  and  104°  F.  The  lowest  morning 
temperature  is  between  6  and  8  a.  m.  ;  the  highest  evening 
temperature  is  between  6  and  9  p.  m. 

During  the  second  week  the  temperature  remains  fairly 
stationary ;  there  are  morning  remissions,  but  these  are 
slight. 

The  temperature  in  the  first  part  of  the  third  week  con- 
tinues like  that  of  the  second  week,  but  toward  the  close  of 
the  third  week  the  morning  remissions  become  more  marked, 
the  evening  rise  remaining  the  same. 

During  the  fourth  week  the  morning  remissions  become 
more  marked,  while  the  evening  exacerbations  decrease ; 
toward  the  close  of  the  week  the  morning  temperature 
becomes  normal,  and,  the  evening  rise  becoming  progress- 
ively less,  the  evening  temperature  becomes  also  normal 
and  the  case  is  completed. 

This  typical  temperature  is  depicted  on  Plate  i.  While 
this  temperature  curve  is  typical  of  typhoid  fever,  such  a 
regular  schematic  chart  is  seldom  met  with  in  actual  prac- 
tice, variations   in  the  course  being  exceedingly  common. 


24  M.tXr.lL    OF   THE   PRACTICE    OE  MED/C/XE. 

The  commonest  variations  of  each  week  will  be  separately 
considered. 

J^rria/ions  iu  tJic  First  Week. — {ii)  It  is  seldom  that  we 
obtain  the  temperature  of  the  first  few  days,  as  the  disease 
begins  so  insidiousl)-  that  it  is  not  until  the  fourth  or  fifth 
day,  as  a  rule,  that  the  patient  comes  under  observation. 
(/^)  Some  cases  plunge  at  once  into  their  fever,  the  onset 
being  sudden,  the  temperature  attaining  its  maximum  upon 
the  second  or  third  day.  This  sudden  onset  is  frequently 
accompanied  b\-  a  chill,  (r)  In  some  cases  the  temperature 
of  the  first  week  is  markedly  remittent,  the  evening  rise 
being  frequently  preceded  by  a  chill  and  followed  by  sweat- 
ing.   Such  cases  are  difficult  to  diagnose  from  malarial  fever. 

Exceptions  to  the  Second  and  Third  Weeks. — {a)  The  tem- 
perature may  fall  to  normal  by  lysis  at  the  close  of  the 
second  week.  These  are  the  cases  in  which  the  lesion  in 
the  glands  docs  not  progress  to  ulceration.  (/;)  During  the 
second  and  third  weeks  the  fever  may  be  slight — between 
99°  and  loi'^  F. — and  the  morning  temperature  may  even 
be  normal.  This  may  indicate  a  mild  attack  if  the  other 
symptoms  be  mild  in  proportion,  but  if  the  other  symptoms 
be  severe  the  low  temperature  is  not  a  good  sign.  These 
cases  with  slight  fever  seem  especially  liable  to  relapses. 
{c)  During  the  third  week  the  temperature  may  remain 
steadily  high  with  but  slight  diurnal  variations.  In  bad 
cases  the  temperature  may  remain  steadily  high,  persisting 
during  the  fourth,  fifth,  sixth,  seventh,  and  eighth  weeks. 
Such  cases  are  apt  to  be  fatal.  In  some  cases  the  temper- 
ature suddenly  mounts  up  before  death,  reaching  a  height 
of  109°  to  111°  F.  (Plate  2,  Fig.  i). 

Exceptions  to  the  Fourth  Week. — The  temperature  may  fall 
somewhat  toward  the  end  of  the  fourth  week,  but  may  still 
continue  a  little  elevated,  running  between  99°,  100°,  and 
101°  F.  until  the  sixth,  seventh,  eighth,  or  ninth  week.  With 
this  slight,  steady  temperature  there  may  be  profuse  sweat- 
ing. These  symptoms  seem  due  to  unhealed  intestinal 
ulcers. 

In  some  cases  a  slight  evening  rise  of  temperature  to  99° 
or  100°  F.  may  be  noticed  during  the  fifth  and  sixth  weeks, 


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TYPHOID   FEVER.  2$ 

without  Other  unfavorable  symptoms.  This  rise  may  be 
due  either  to  a  depressed  nervous  state  or  to  some  insidious 
comphcation.  A  sudden  fall  in  the  temperature  with  a 
subsequent  rise  is  significant  of  an  intestinal  hemorrhage. 
The  more  severe  the  hemorrhage  the  more  decided  the 
initial  fall  of  temperature  (Plate  2,  Fig.   2). 

The  further  modifications  in  the  temperature  caused  by 
complications,  and  the  relapses,  will  be  considered  under 
separate  headings. 

Ptilse. — During  the  first  week  the  pulse  is  full,  dicrotic, 
and  about  100.  During  the  second  and  third  weeks  it 
becomes  quicker  and  feebler  in  direct  proportion  to  the 
gravity  of  the  case.  A  pulse  persistently  over  140  is  of 
serious  import.  In  some  cases  the  pulse  is  feeble  without 
being  rapid.  The  weakness  of  the  heart's  action  is  of  more 
consequence  than  mere  rapidity,  and  may  endanger  the  life 
of  the  patient,  especially  during  the  third  and  fourth  weeks. 
In  some  cases  there  may  be  attacks  of  syncope  or  even 
collapse,  in  either  of  which  the  patient  may  die.  In  other 
cases  the  feebleness  of  the  heart  allows  of  venous  conges- 
tion and  cyanosis,  which  further  endanger  the  life  of  the 
patient.  From  the  poor  circulation  thrombi  may  occur  in 
any  of  the  larger  veins.  A  sudden  marked  increase  in  the 
rapidity  and  feebleness  of  the  pulse  indicates,  as  a  rule, 
perforation  or  hemorrhage. 

Gastro-intestinal  Synipioins. — The  appetite  is  lost  early  in 
the  disease,  and  does  not  return  until  convalescence. 

The  tongue  at  first  is  moist  and  coated.  In  severe  cases 
it  has  a  tendency  to  become  dry,  due  rather  to  the  severity 
of  the  disease  than  to  the  fever.  In  very  severe  cases  the 
tongue  becomes  dry  and  brown,  and  brownish  crusts,  or 
sordes,  collect  upon  the  teeth  and  gums,  interfering  with 
articulation  and  deglutition.     This  is  a  bad  sign. 

The  pharynx  is  usually  inflamed  during  the  first  week  of 
the  disease. 

Nansca  and  vomiting  may  occur  at  any  time  in  the  dis- 
ease, but  they  are  not  usually  severe  if  the  diet  and  medi- 
cation be  judicious.     In  some  cases,  however,  vomiting  is 


26  MAXi'AL    OF   THE   PKACTICE    OF  MEDICIXE. 

SO  severe  as  to  interfere  with  the  feeding  of  the  patient,  and 
it  may  even  cause  death  by  exhaustion. 

Diah'hcca  is  usually  present,  althou<^h  in  some  places,  as 
in  New  York,  and  in  certain  epidemics  constipation  is  the 
rule.  The  diarrhoea  depends  less  upon  the  extent  of  the 
ulcerations  than  upon  the  severity  of  the  associated  enteritis, 
and  it  is  rarely  marked  until  after  the  beginning  of  the 
second  week.  It  may  last  a  few  days  only  or  may  continue 
throughout  the  disease,  or  it  may  alternate  with  constipation. 
The  stools  are  abundant,  thin,  offensive,  and  of  a  grayish- 
yellow  color,  and  are  described  as  suggestive  of  pea  soup. 
It  is  a  true  fecal  diarrhoea,  resembling  the  normal  contents 
of  the  small  intestine.  The  passages  var}'  in  number  from 
two  to  five  daily,  more  frequent  passages  being  rare.  The 
common  occurrence  of  constipation  as  a  symptom  must 
always  be  borne  in  mind. 

Tyvipanitcs  develops  in  the  second  week  in  a  great 
majority  of  cases,  and  it  is  due  to  paresis  of  the  inflamed 
intestinal  wall  interfering  with  peristalsis.  Tympanites 
usually  causes  bulging  of  the  abdominal  wall,  although  in 
some  cases  rigidity  on  palpation  is  alone  detected.  When 
once  developed  it  is  apt  to  persist  throughout  the  disease. 
In  moderate  degree  it  does  no  more  actual  harm  than  to 
render  the  patient  uncomfortable,  but  if  excessive  it  dis- 
places the  diaphragm  upward,  interferes  with  the  action  of 
heart  and  lungs,  excites  nausea  and  vomiting,  and  increases 
the  danger  of  perforation.  Tympanites  is  a  sign  of  serious 
import. 

Pain  and  toidcrncss  over  the  abdomen  are  commonly  ob- 
served, and  are  usually  more  pronounced  in  the  right  iliac 
fossa.     These  symptoms  are  of  no  diagnostic  significance. 

Gurgling  in  the  right  iliac  fossa  is  too  common  in  other 
diseases  to  be  distinctive. 

HcmorrJiagcs  from  the  bowels  are  a  serious  symptom. 
It  is  important  to  distinguish  the  sources  of  bleeding. 

(i)  There  may  appear  slight  hemorrhages  during  the 
first  ten  days  of  the  disease,  coming  not  from  ulcers,  for 
none    exist   at   so   early  a  date,   but  from    the  congested 


TYPHOID   FEVEK.  2/ 

mucous  membrane.     They  are  trifling  in  amount,  and  indi- 
cate merely  a  severe  degree  of  complicating  enteritis. 

(2)  The  characteristic  hemorrhages  of  the  disease  occur 
after  the  close  of  the  second  week,  and  are  caused  by  the 
separation  of  the  sloughs  from  the  intestinal  ulcerations. 
They  occur  in  about  5  per  cent,  of  cases,  and  are  always 
of  grave  significance,  for  not  only  is  the  hemorrhage  fre- 
quently fatal  in  itself,  but  it  also  denotes  extensive  and  deep 
intestinal  ulceration.  The  hemorrhage  varies  in  amount 
from  a  few  drops  to  several  pints  or  more.  When  once  a 
hemorrhage  has  occurred,  others  are  liable  to  follow.  The 
blood  passed  by  the  rectum  may  be  fluid  and  red,  or  dark 
and  clotted,  or  even  tarry  in  appearance,  according  to  its 
amount  and  the  length  of  time  it  has  been  retained  in  the 
bowel.  In  some  cases  of  rapidly  fatal  hemorrhage  death 
may  ensue  before  any  blood  at  all  has  been  passed.  The 
symptoms  caused  by  a  severe  hemorrhage  appear  suddenly 
— faintness,  syncope,  even  collapse,  a  rapid  and  feeble  pulse, 
great  dyspnoea  with  restlessness  (the  so-called  "air-hunger"), 
great  pallor,  and  cold  extremities.  The  mind,  if  clouded 
before,  usually  becomes  clear  and  active.  The  temperature, 
as  shown  on  Plate  2,  Fig.  2,  undergoes  a  fall  of  several 
degrees,  perhaps  to  normal  or  even  to  subnormal,  and  this 
is  followed  usually  by  a  subsequent  rise  to  a  higher  plane 
than  before  the  hemorrhage.  From  such  a  hemorrhage  the 
patient  may  die  in  acute  anaemia.  In  some  rare  cases  the 
hemorrhage  seems  to  exert  a  beneficial  effect  upon  the 
course  of  the  disease.  Subsequent  hemorrhages  may  follow 
at  intervals. 

(3)  During  convalescence  there  may  be  small  repeated 
hemorrhages  without  other  unfavorable  symptoms.  These 
hemorrhages  come  from  sluggish  ulcers  which  have  not  yet 
cicatrized. 

Nervous  Symptoms. — During  the  first  week  headache  is 
usually  a  pronounced  symptom.  It  is  usually  dull  in 
character,  although  in  rare  cases  it  may  be  severe,  sharp, 
and  associated  with  photophobia  and  convulsive  twitchings, 
closely  resembling  in  this  respect  the  headache  of  menin- 
gitis.    During  the  first  week  there  are  apt  to  be  sleeplessness 


28  jMAXi'AL    OF   THE   PRACTICE    OF  MEDICINE. 

and  restlessness  at  night.  Associated  with  the  headache 
there  is  often  nose-bleed  during  the  first  week. 

During  the  second  week  the  headache  and  restlessness 
give  way  to  a  mental  apathy  which  is  exceedingly  charac- 
teristic. The  face  is  utterly  without  vivacity,  with  a  vacant, 
listless  expression.  The  pupils  are  generally  dilated.  The 
patients  answer  questions  correctly,  although  with  apparent 
lack  of  effort  and  interest,  and  often  respond  only  to  re- 
peated and  persistent  questioning.  If  left  alone,  they  lie 
quietly  and  do  not  seem  to  take  any  concern  about  them- 
selves. This  condition  of  apathy  is  in  sharp  contrast  to 
the  animated,  cheerful  condition  of  acute  miliary  tuber- 
culosis, and  is  a  strong  point  of  differential  diagnosis  be- 
tween the  two  diseases.  It  is  important  to  remember  that 
in  rare  cases  this  apathy  is  not  seen. 

Delirium  is  seen  in  the  majority  of  cases,  varying  in 
degree  from  confusion  of  ideas  to  acute  mania ;  it  is,  how- 
ever, less  commonly  seen  than  formerly,  owing  to  im- 
proved therapeutics.  During  the  first  week  there  may 
occur  a  delirium  which  is  apt  to  be  acute  and  violent.  This 
condition,  however,  is  not  common.  The  commonest  form 
of  delirium,  which  appears  after  the  second  week  of  the  dis- 
ease, is  of  the  low  muttering  variety,  the  patient  lying  quietly 
and  talking  incoherently.  This  form  more  usually  appears 
only  at  night,  although  it  may  in  severe  cases  last  into  the 
daytime  as  well.  There  may  be  a  disposition  of  the  patient 
to  get  out  of  bed,  requiring  careful  watching.  This  delirium 
often  alternates  with  periods  of  stupor  which  may  become 
more  profound,  passing  into  semi-coma  or  even  coma.  In 
a  few  cases  this  form  of  delirium  alternates  with  a  more 
active  and  noisy  variety.  In  many  cases  there  appears  no 
delirium  at  all,  and  the  number  of  these  cases  seems  to 
increase  with  the  increasing  applications  of  the  hydropathic 
and  antipyretic  treatment  of  the  disease. 

In  all  cases  muscular  prostration  is  noticeable  from  the 
first  and  increases  with  the  disease.  There  may  be  mus- 
cular weakness  of  the  bladder,  causing  retention  of  urine. 
The  passage  of  urine  should  always  be  inquired  about,  as 
the  patient  may   not  speak  of  it  because  of   the  mental 


TYPIJOID   FEVER.  29 

apathy  of  the  disease.  There  may  be  weakness  of  the 
sphincter  ani  with  incontinence  of  feces. 

In  bad  cases  there  are  twitchings  and  automatic  move- 
ments of  the  muscles,  especially  of  the  hands.  These 
symptoms,  frequently  spoken  of  as  "  subsultus  tendinum" 
and  "carpholog-ia,"  belong  to  the  latter  part  of  the  disease. 
In  rarer  cases  convulsive  movements  and  muscular  rigidity 
are  seen  in  the  first  week  of  the  disease,  associated  with  the 
acute  headache  already  alluded  to. 

Hyperaesthesia  of  the  skin,  which  is  occasionally  met 
with,  may  be  extreme. 

Spleen. — The  spleen  is  almost  invariably  increased  in 
size,  the  enlargement  being  usually  appreciable  by  the  close 
of  the  first  week.  After  the  third  week  it  diminishes  in 
size.  In  rare  cases  the  spleen  may  remain  normal  in  size 
should  there  be  depletion  by  severe  diarrhoea  or  by  hemor- 
rhage. The  enlargement  of  the  spleen  is  more  accurately 
determined  by  palpation  than  by  percussion,  as  the  splenic 
area  is  apt  to  be  obscured  by  tympanites.  In  the  majority 
of  cases  the  spleen  is  tender  on  palpation. 

Urine. — The  urine  shows  during  the  first  week  the  changes 
commonly  seen  in  fever,  being  concentrated  and  depositing 
urates  on  cooling.  During  the  course  of  the  disease  it  is 
apt  to  contain  a  little  albumin  and  casts  from  parenchyma- 
tous degeneration  of  the  kidney,  which  degeneration,  how- 
ever, is  never  very  severe.  Ehrlich  describes  a  color  reac- 
tion which  he  considers  characteristic  of  typhoid  fever. 
To  employ  the  test  two  solutions  are  prepared,  one  a  Yz  per 
cent,  solution  of  sodium  nitrite,  the  other  a  Y  per  cent, 
solution  of  hydrochloric  acid  saturated  with  sulphanilic 
acid ;  40  parts  of  the  first  solution  are  mixed  with  i  part  of 
the  second,  and  equal  parts  of  this  mixture  and  urine  are 
thoroughly  shaken  in  a  test-tube.  Upon  the  addition  of 
ammonia  a  brownish-red  reaction  is  observed,  whereas  in 
normal  urine  a  brownish-yellow,  without  any  reddish,  tinge 
is  observed.  This  reaction  is  not  obtained  after  the  third 
week  of  the  disease ;  but,  while  present  during  the  earlier 
stages  of  the  fever,  it  is  not  considered  a  pathognomonic 


30  MANUAL    OF   THE   PRACTICE    OF  MEDIC  EXE. 

test,  as  it  may  be  seen  in  other  diseases,  such  as  acute 
tuberculosis  or  measles. 

Eruption. — The  eruption  of  typhoid  fever  is  very  charac- 
teristic. It  consists  of  small  round  spots,  about  pin-head 
in  size,  of  a  rose-pink  color  which  disappears  on  pres- 
sure, the  spots  being  slightly  elevated.  In  severe  cases 
they  may  be  hemorrhagic.  They  appear  usually  from  the 
seventh  to  the  twelfth  day,  although  they  may  be  seen  as 
early  as  the  third  and  as  late  as  the  twentieth  day.  They 
are  present  in  typical  relapses.  They  appear  in  successive 
crops,  each  crop  lasting  two  or  three  days,  but  they  do  not 
appear  after  the  third  week.  They  usually  are  seen  on  the 
abdomen,  but  may  be  found  on  the  chest,  thighs,  and  back 
as  well,  and  in  rare  cases  may  be  more  generally  distributed. 
The  eruption  is  usually  scanty.  There  may  be  only  two  or 
three  spots,  and  unless  care  is  exercised  they  may  be  over- 
looked entirely. 

Blood. — The  blood-serum  of  patients  with  typhoid  fever 
possesses  the  property  of  causing  arrest  of  motility  and 
agglutination  of  the  specific  bacilli  when  added  to  pure 
culture.  This  is  the  so-called  Widal  reaction,  and  is  of 
importance  in  diagnosis.  The  reaction  is  rarely  absent, 
although  it  may  be  delayed  until  the  third  week  or  even 
until  a  relapse,  and  the  reaction  may  be  present  months 
after  the  original  attack.  It  is  of  importance  when  present, 
as  it  occurs  in  no  other  disease,  but  negative  results  in  the 
early  stages  of  typhoid  mean  nothing. 

Leucocytosis  in  typhoid  fever  is  not  marked.  When  a 
leucocytosis  of  twelve  to  fifteen  thousand  or  over  occurs, 
a  complication  is  to  be  suspected. 

Course  of  the  Disease. — IncKbation. — The  period  of 
incubation  lasts  a  week  or  ten  days,  during  which  time  there 
are  apt  to  be  indefinite  symptoms — headache,  lassitude,  and 
slight  digestive  disturbances.  These  symptoms  are  neither 
characteristic  nor  well  marked. 

The  onset  is  usually  gradual,  so  that  it  is  hard  to  tell 
exactly  the  first  appearance  of  the  disease;  in  practice, 
however,  the  first  noted  advent  of  fever  is  considered  the 
definite  time  of  onset. 


TYPIIOfD   J' EVER.  3  I 

During-  the  first  week  the  temperature  rises  from  day  to 
day ;  there  are  sore  throat  and  probably  epistaxis,  dull 
headache  with  sleeplessness  and  restlessness,  possibly  a  lit- 
tle wandering  at  night,  and  a  slight  apathetic  condition  dur- 
ing the  day.  The  appetite  is  wholly  lost.  There  may  be 
nausea  or  vomiting ;  the  bowels  may  be  either  loose  or  con- 
fined. The  pulse  varies  from  80  to  lOO  and  is  of  fair  force. 
By  the  end  of  the  week  the  spleen  is  felt  enlarged  and  the 
eruption  appears  on  the  abdomen.  Patients  differ  consider- 
ably as  to  the  severity  of  these  symptoms  and  as  to  their 
reaction  to  them,  some  patients  being  much  prostrated, 
while  others  even  well  advanced  in  the  disease  are  around 
and  out.  These  "walking  cases"  are  more  usually  seen  in 
hospital  practice,  and  they  greatly  increase  the  mortality 
rate.  These  walking  cases  may  not  come  under  observation 
until  hemorrhage  or  perforation  has  occurred. 

Occasionally  the  onset  is  more  acute.  {a)  In  some 
cases  the  disease  begins  with  a  chill  and  a  rapid  rise  of  tem- 
perature, {b)  In  other  cases  there  appear  acute  nervous 
symptoms  resembling  those  of  meningitis — headache,  pho- 
tophobia, rigidity  of  the  neck,  and  muscular  twitching,  [c) 
In  other  cases  the  onset  of  the  disease  is  accompanied  by 
severe  bronchitis,  which  renders  the  diagnosis  between 
typhoid  fever  and  acute  tuberculosis  one  of  great  difficulty. 
[d)  In  other  cases  the  disease  may  be  ushered  in  by  severe 
nausea  and  vomiting,  while  in  rare  cases  the  symptoms  of 
acute  nephritis,  with  smoky  urine  containing  albumin  and 
casts,  are  the  first  observed. 

During  the  second  week  the  symptoms  become  aggravated; 
the  temperature  remains  steadily  high,  and  the  headache 
gives  way  to  mental  apathy.  There  may  be  at  night  sleep- 
lessness and  slight  delirium,  which  in  severe  cases  continues 
at  intervals  into  the  day.  The  pulse  is  a  little  more  rapid 
and  feeble.  The  eruption  is  more  apparent.  The  lips  and 
tongue  are  apt  to  be  dry.  Prostration  becomes  more  and 
more  marked.  There  may  be  diarrhoea  or  constipation. 
There  is  apt  to  be  meteorism.  At  the  close  of  the  week 
the  patient  may  die  with  severe  nervous  symptoms  or  from 
an  early  hemorrhage  or  from  perforation,  while  very  mild 


32  MAXUAL    OF  THE   PRACTICE    OF  MEDICIXE. 

cases  may  defcrvesce.  These  mild  cases  defervescing-  at  the 
close  of  the  second  week  are  frequently  spoken  of  as 
"  aborted  typhoids,"  and  constitute  the  set  of  cases  in 
which  the  intestinal  lesion  does  not  progress  to  ulceration. 

During  the  third  week  the  temperature  remains  high,  but 
the  morning  remissions  become  more  marked.  The  pulse 
is  more  rapid  and  feeble,  with  a  tendency  to  heart  failure  in 
severe  cases.  Cerebral  symptoms  are  prominent,  the  apathy 
alternating  with  muttering  delirium.  Emaciation  and 
prostration  are  extreme.  The  tongue  becomes  dryish. 
There  may  be  retention  of  urine  and  incontinence  of 
feces.  During  the  third  week  there  is  danger  of  perfora- 
tion, peritonitis,  hemorrhage,  and  pulmonary  complications. 

During  the  fourtJi  iveek  the  temperature  finally  reaches 
the  normal,  the  pulse  becomes  stronger,  cerebral  symptoms 
disappear,  the  tongue  becomes  moist  and  clean,  and  the 
patient  complains  only  of  hunger  and  weakness.  In  some 
cases  the  fourth  week  may  show  no  improvement  over  the 
third,  but  the  symptoms  will  continue  into  the  fifth,  sixth,  or 
seventh  week  without  mitigation.  At  the  end  of  this  time 
the  symptoms  may  improve  and  the  patient  recover,  or  they 
may  become  more  pronounced  and  lead  to  a  fatal  termina- 
tion. In  other  cases  the  temperature  begins  to  fall  in  the 
fourth  week,  but  does  not  quite  come  down  to  normal,  the 
patient  continuing  with  a  slight  irregular  fever  for  from  one 
to  three  weeks  longer.  In  severe  cases  this  fever  is  ac- 
companied by  a  continuance  of  general  symptoms  to 
some  degree,  the  protraction  of  convalescence  being  due  to 
unhealed  intestinal  ulcers.  In  others,  although  the  fever 
continues  in  this  way,  the  general  symptoms  rapidly  dis- 
appear, and  the  patient  improves  daih'.  These  cases  seem 
due  to  post-febrile  anaemia  or  to  nerve-exhaustion. 

Insidious  Cases. — Besides  this  regular  form  we  find  cases 
of  an  irregular  type.  These  cases  are  usually  seen  in 
epidemics  of  some  size,  and  they  run  an  insidious  course. 
The  pulse  is  but  slightly  affected,  and  the  temperature  is 
but  slightly  increased,  varying  between  99°  and  100°  F.  In 
rare  cases  there  is  no  fever.  Headache,  restlessness,  sleep- 
lessness, and  prostration  are  noticed.     There  may  be  diar- 


TYPHOID   FEVER.  33 

rhoea  or  constipation,  but  the  enlargement  of  the  spleen  and 
the  eruption  are  the  only  marked  characteristic  symptoms. 
These  cases  may  not  be  sick  enough  to  be  in  bed,  or  even 
in  the  house ;  the  course  is  about  four  weeks,  and  while  the 
prognosis  is  generally  good,  such  light  cases  are  as  liable 
as  the  severer  forms  to  hemorrhage  and  perforation. 

Typhoid  in  CJiildren. — Typhoid  fever  in  children  differs 
from  that  in  adults  in  that  there  is  less  danger  of  hemor- 
rhage or  perforation,  the  pulse  is  more  apt  to  be  rapid  and 
feeble,  the  cerebral  symptoms  are  more  prominent,  and  the 
temperature  reaches  its  maximum  earlier  in  the  disease, 
is  more  remittent  (hence  often  called  "  infantile  remittent 
fever  "),  and  often  falls  by  crisis.  The  eruption  is  frequently 
slight  or  absent. 

Typhoid  in  the  Aged. — Typhoid  fever  in  the  aged  runs  an 
insidious  and  frequently  a  fatal  course.  The  temperature 
is  not  so  high  as  in  adults,  but  the  cerebral  symptoms  and 
prostration  are  more  marked.  Hypostatic  pneumonia, 
heart  failure,  and  nephritis  are  frequent  complications. 

Complications. — Perforation  of  the  intestine,  which  is  a 
most  serious  complication,  occurs  in  6  per  cent,  of  cases.  It 
is  rare  before  the  third  week,  although  it  has  been  noted  on 
the  eighth  day.  It  may  occur  in  convalescence.  It  is  more 
apt  to  occur  in  severe  cases  frequently  associated  with  hem- 
orrhage. It  seems  to  be  favored  by  meteorism,  vomiting, 
and  dietetic  errors.  The  intestinal  contents  entering  the 
peritoneal  cavity,  there  results  perforating  peritonitis. 

In  very  severe  perforations  the  first  symptom  is  pain  in 
the  abdomen,  followed  by  a  lowering  of  the  temperature 
with  a  subsequent  rise,  collapse,  and  death  in  a  few  hours, 
the  condition  of  peritoneal  septicaemia  being  produced.  In 
less  severe  cases  there  is  time  for  the  production  of  a  puru- 
lent peritonitis,  which  runs  a  course  with  typical  symptoms, 
or,  should  the  patient  already  be  severely  ill,  the  abdominal 
symptoms  will  be  less  marked,  there  may  only  be  an  increase 
of  temperature,  a  more  rapid  and  feeble  pulse,  and  a  hastened 
fatal  termination.  Diagnosis  in  such  cases  is  difficult,  espe- 
cially if  there  previously  existed  abdominal  tenderness  and 
tympanites.     Peritonitis  with  the    above  symptoms  is  also 


34  MAXi'AL    OF   THE   PRACTICE    OF  MEDICIXE. 

.seen  as  the  result  of  any  of  the  other  causes  mentioned 
under  the  head  oi  hsio)is.  Sucli  a  non-perforative  peritonitis 
runs  a  longer  course  and  nia)^  be  recovered  from. 

The  other  complications  oS.  t}-phoid  are  various,  and  only 
a  brief  mention  of  the  most  important  can  be  made. 

The  pharynx  is  often  inflamed  in  the  first  week.  Otitis 
media  may  occur  at  any  time.  Parotitis  may  occur  in  the 
third  or  the  fourth  week  and  may  proceed  to  suppuration. 

The  larynx  maybe  the  seat  of  a  catarrhal  inflammation  or 
of  ulceration.  There  may  be  oedema  of  the  glottis  or  peri- 
chondritis of  the  arytenoid  cartilages,  which  may  eventuate 
in  necrosis  of  the  cartilages. 

Bronchitis  is  common  at  any  time  of  the  disease. 

Broncho-pneumonia  and  hypostatic  pneumonia  are  seen 
in  severe  cases.  They  add  but  few  subjective  symptoms, 
being  marked  by  the  regular  symptoms  of  the  disease  and 
by  the  apathetic  condition  of  the  patient.  The  temperature 
is  apt  to  be  raised,  the  pulse  becomes  weaker  and  quicker, 
and  the  physical  signs  are  present. 

Lobar  pneumonia,  gangrene  of  the  lung,  and  pleurisy  with 
effusion  are  occasionally  seen. 

Thrombosis  of  the  femoral  vein  is  frequently  seen,  accom- 
panied by  pain  and  oedema  and  by  the  cord-like  feeling  of 
the  vein. 

Catarrhal  or  croupous  enteritis  or  colitis  may  occur  in 
severe  degree. 

Albumin  and  casts  are  usually  present  in  the  urine  in 
small  amounts,  from  a  mild  form  of  acute  degeneration  of 
the  kidney.  Less  frequently  there  is  an  acute  exudative 
nephritis  with  diminution  in  the  amount  of  urine  and  con- 
siderable amount  of  albumin  and  casts.  In  rare  cases  the 
urine  may  be  suppressed.  When  the  kidney  is  involved  in 
this  way  there  are  not  apt  to  be  ura;mic  symptoms,  but  the 
temperature  and  pulse  are  affected  for  the  worse,  and  the 
patient  is  apt  to  do  badly. 

There  may  be  pyelitis,  with  the  passage  of  mucus  and 
pus  from  the  kidney ;  in  the  urine  either  Eberth's  bacillus 
or  the  colon  bacillus  may  be  found. 


TYPHOID   /■•/■:  TEA'.  35 

Subcutaneous  or  subperiosteal  abscesses  may  develop,  in 
the  latter  case  frequently  associated  with  caries  or  necrosis 
of  the  bone.  In  these  abscesses  Eberth's  bacilli  are  found 
sometimes  with  the  colon  bacilli.  These  periosteal  ab- 
scesses may  appear  during  convalescence,  and  are  very 
slow  in  healing". 

Malarial  infection  may  complicate  typhoid  fever  at  any 
time.  During  the  course  of  the  fever  the  added  infection 
gives  a  remittent  character  to  the  temperature-curve,  while 
if  the  malarial  infection  show  itself  during  convalescence, 
the  temperature  is  more  characteristic,  being  markedly  re- 
mittent or  even  intermittent.  Examination  of  the  blood 
shows  the  presence  of  the  malarial  organism. 

Relapses  and  Recrudescences. — Relapses  are  seen  in 
from  3  to  1 8  per  cent,  of  the  cases,  varying  in  the  different 
epidemics.  A  relapse  is  a  second  attack  of  typhoid  with 
a  repetition  of  the  symptoms  of  the  first  attack,  and  is  pro- 
duced by  a  reinfection  of  the  intestine  from  sloughs  derived 
from  some  part  above.  The  intermission  between  the 
original  attack  and  the  beginning  of  the  relapse  may  extend 
to  twenty-five  days,  the  usual  period  being  from  five  to 
eight  days.  It  is  not  necessary  to  have  an  intervening 
period  without  high  temperature,  as  the  relapse  may  occur 
in  the  fourth  week,  before  the  temperature  comes  down  to 
normal.  There  may  be  only  one  relapse  or  there  may  be 
several,  becoming  progressively  milder  and  occurring  at 
longer  intervals.  The  symptoms  appear  sooner  and  are 
of  shorter  duration  than  those  of  the  primary  attack.  The 
temperature  attains  its  maximum  on  the  third  to  the  fifth 
day ;  the  eruption  is  scanty,  and  as  a  rule  appears  on  the  third, 
fourth,  or  fifth  day.  The  other  symptoms  are  much  less 
severe  than  those  of  the  primary  attack.  The  duration  of 
the  relapse  is  usually  from  ten  to  fourteen  days,  although  it 
may  last  as  long  as  thirty-nine  days. 

The  conditions  predisposing  to  relapse  are  not  known, 
although  it  seems  as  if  constipation  were  a  predisposing 
factor. 

Relapses    are    to    be    distinguished    from    the    so-called 


36  M.-IXrAL    OF   THE   PRACTICE    OF  MEDICIXE. 

"  recrudescences,"  or  temporary  rises  of  temperature,  of 
convalescence.  These  rises  usually  occur  from  dietetic 
errors  or  from  over-exertion.  We  have  a  rise  of  tempera- 
ture occurring^  suddenly  and  remaining  for  from  one  to  five 
days  without  the  enlargement  of  the  spleen  or  the  eruption. 
These  recrudescences  do  not  add  anj' element  of  danger : 
they  only  retard  convalescence  by  just  so  much.  Plate  2, 
Fig,  I,  shows  the  temperature  of  recrudescence  alone, 
and  Plate  3  shows  the  temperature  of  recrudescence  and 
relapse. 

Convalescence  is  always  slow  and  tedious,  usually  re- 
quiring months  before  the  patient  is  in  robust  health  again. 
Convalescence  may  be  interrupted  in  several  ways.  There 
may  be  an  irregular  fever  which  will  last  for  several  weeks. 
There  may  be  perforation  or  hemorrhage  or  peritonitis 
during  convalescence.  The  mind  may  remain  feeble  for 
days  or  weeks.  Some  patients  can  hardly  be  said  to  con- 
valesce at  all,  but  remain  feeble,  emaciated,  and  anaemic, 
and  die  exhausted,  the  autopsy  usually  revealing  extensive 
cicatrices.  There  may  be  peripheral  neuritis  with  paralysis 
of  groups  of  muscles.  Gastro-intestinal  symptoms  may  per- 
sist— vomiting,  diarrhcea,  or  dysentery.  The  hair  usually 
falls  out  during  convalescence,  but  grows  again. 

The  prognosis  varies  in  hospital  and  private  practice 
and  in  various  epidemics.  The  mortality  in  mild  epidemics 
is  from  5  to  15  per  cent. ;  in  hospital  practice,  from  15  to  25 
per  cent.  In  the  German  military  hospitals,  when  the 
patients  are  young  and  vigorous  and  are  treated  early,  the 
mortality  is  from  i  to  8  per  cent.  A  guarded  prognosis 
must  always  be  given,  as  mild  cases  may  turn  out  badly 
and  serious  cases  may  recover.  The  liability  to  perforation, 
peritonitis,  or  hemorrhage  lends  unknown  factors  to  each 
case.  As  a  rule,  patients  with  high  and  continuous  temper- 
ature, or  with  an  early  involvement  of  nervous  centres,  as 
shown  by  muttering  delirium  with  muscular  tremors  or  with 
excessive  meteorism  and  diarrhoea,  are  apt  to  do  badly. 
The  earlier  a  patient  is  treated  and  sent  to  bed,  the  better 
the  prognosis.     Fat,  elderly  people  and  those  addicted  to 


TYPHOID   FF.VER.  3/ 

alcohol  stand  the  disease  badly.  Perforation  and  peritonitis 
are  nearly  uniformly  fatal.  Recovery  from  a  relapse  is  to 
be  expected,  as  the  symptoms  are  rarely  severe,  and  per- 
foration, hemorrhage,  and  peritonitis  are  infrequent. 

Treatment. — P^'ophy lactic. — Typhoid  fever  is  largely  a 
preventable  disease,  and  the  prophylactic  treatment  consists 
in  destroying  the  germ  where  it  is  known  to  exist,  and  in 
preventing  its  admission  to  the  human  body.  To  accom- 
plish the  first  object  the  following  rules  should  be  rigor- 
ously obeyed,  and  be  persisted  in  until  convalescence  is 
thoroughly  established : 

The  bed-linen  and  the  clothes  of  the  patient  must  be 
boiled  for  at  least  half  an  hour  after  being  soaked  in  a  strong 
antiseptic  solution.  The  following  are  types  of  the  disin- 
fectant solution  to  be  employed : 

I^.  Bichloride  of  mercury,  3ij ; 

Potassium  permanganate,  3ij ; 

Water,  i  gallon. — M. 

I^.  Chloride  of  lime  (best  quality),  siv; 

Water,  i  gallon. — M. 

Those  washing  or  handling  soiled  bed-linen  must  cleanse 
their  hands  frequently  in  one  of  these  solutions,  especially 
before  eating. 

The  intestinal  discharges,  urine,  and  vomited  matters  must 
be  mixed  thoroughly  with  sufficient  disinfecting  fluid  for  at 
least  half  an  hour  before  being  emptied  from  the  vessel. 
From  time  to  time  disinfecting  fluid  must  be  poured  down 
water-closets  or  privy-vaults.  The  discharges  must  not  be 
emptied  into  any  privy-vault  that  is  near  the  water-supply. 

The  nates  of  the  patient  must  be  cleansed  and  disinfected 
thoroughly  after  each  defecation. 

To  prevent  the  admission  of  the  germ  into  the  body  the 
drainage,  the  sewage,  and  the  water-supply  must  be  sani- 
tary. The  source  of  every  epidemic  should  be  traced  in  the 
most  painstaking  manner,  and  means  should  be  taken  to 
avert  future  infection.  During  an  epidemic  drinking-water 
and  milk  should  be  boiled,  and  care  should  be  exercised 


38  MAXC.4L    OF  THE   PRACTICE    OF  MEDICINE. 

that  ice  taken  from  polluted  water  is  not  used.  With 
perfect  disinfection  of  the  dejecta  and  with  perfect  drainage 
not  allowing  pollution  of  water-supplies,  typhoid  fever 
should  never  occur. 

General  JManagevieiit. — The  patient  should  be  put  to  bed 
as  early  as  possible,  and  be  kept  there  until  convalescence 
has  been  established  for  one  week.  The  use  of  the  bed-pan 
and  urinal  should  be  insisted  on.  The  room  should  be 
large,  airy,  and  moderately  cool.  Care  should  be  taken  to 
prevent  bed-sores  by  keeping  the  sheets  smooth  and  clean 
and  by  washing  the  patient's  back  morning  and  night  with 
alcohol  and  tannic  acid,  and  after  careful  drying  dusting  it 
with  starch-powder  or  with  bismuth.  The  mouth  and  the 
teeth  should  be  kept  scrupulously  clean,  to  avoid  infection 
of  the  middle  ear  and  of  the  parotid  gland.  Moreover,  by 
cleansing  the  mouth  the  liability  to  pneumonia  and  stomach 
fermentation  is  much  lessened.  For  this  purpose  listerine 
and  water  (i  :  8)  or  boracic-acid  solutions  (i  :  24)  are  of  ser- 
vice. The  services  of  a  good  nurse  should  be  obtained,  as 
nursing  is  one  of  the  most  important  factors  in  the  treat- 
ment of  the  case.     In  severe  cases  two  nurses  are  necessary. 

The  diet  should  be  fluid  and  easily  digestible,  milk  being 
the  ideal  food.  If  given  properly,  there  are  but  very  few 
patients  who  cannot  take  it.  From  three  to  four  pints 
should  be  given  in  the  twenty-four  hours,  in  divided  quanti- 
ties at  short  intervals.  As  a  practical  rule,  a  glassful  every 
two  hours  in  the  day  and  when  awake  at  night  will  guide  its 
administration  in  the  majority  of  cases.  Personal  attention 
must  be  given  to  the  feeding  of  the  patient  to  know  exactly 
how  much  is  taken  and  how  well  it  is  borne.  In  case  pure 
milk  is  not  well  borne,  as  shown  by  nausea  or  vomiting,  or 
by  the  finding  of  undigested  curds  in  the  stools,  the  milk 
should  be  reduced  in  quantity  or  be  diluted  with  lime-water 
or  any  of  the  aerated  waters,  or  should  be  peptonized.  In 
case  these  measures  fail,  the  patient  may  be  fed  with  koumiss 
or  with  matzoon.  In  the  rare  cases  in  which  milk  cannot  be 
taken  at  all  the  reliable  preparations  of  beef  peptonoids,  beef 
tea,  white  of  tgg  with  water,  Nestle's  food,  etc.  may  be  given 
in  its  stead,  although  they  are  to  be  avoided  if  possible. 


TYrilOID    FEVER.  39 

Alcohol  should  not  be  given  as  a  routine  treatment,  but  only 
when  especial  indications  for  it  arise. 

Medical  Treatment. — As  there  is  no  specific  drug  capable 
of  exerting  a  direct  cure  for  the  disease,  the  treatment  is 
mainly  an  expectant  one,  controlling  those  symptoms  that 
exert  a  baneful  effect  on  the  patient,  threaten  his  recovery, 
and  cause  him  discomfort.  The  only  internal  treatment  that 
seems  to  be  of  any  service  is  the  use  of  intestinal  antiseptics 
for  disinfecting  the  alimentary  tract,  to  prevent  fermentation 
and  tympanites,  and  to  guard,  if  possible,  against  auto-infec- 
tion and  relapses.  The  drugs  used  are  salol,  ^-naphthol, 
bismuth  salicylate,  and  creosote,  and  high  enemata  of  weak 
tannic-acid  solutions.  These  measures  seem  in  some  cases 
to  be  of  service.  Except  for  these,  the  treatment  is  entirely 
symptomatic. 

Fever. — In  the  treatment  of  the  fever  there  exists  a  diver- 
sity of  opinion,  some  recommending  its  reduction  as  soon 
as  a  moderate  point  is  reached  (102.5°  F.),  others  preferring 
the  temperature  to  run  its  own  course  unless  it  reaches  too 
high  a  degree  (105°  to  106°  F.).  It  is  certain  that  the  mor- 
tality of  typhoid  has  been  lessened  materially  by  antipyretic 
treatment,  and  that  whereas  a  few  patients  seem  to  be  no 
worse  for  their  fever,  in  the  great  majority  of  cases  the  re- 
duction of  the  fever  is  accompanied  by  an  improvement  of 
all  the  symptoms.  It  seems,  then,  that  the  best  treatment 
is  to  keep  the  temperature  reduced,  provided  this  can  be 
done  without  harm  or  risk  to  the  patient.  The  best  method 
of  doing  this  is  by  the  use  of  hydrotherapy,  first  insisted  on 
by  Brand,  but  modified  to  suit  individual  cases,  no  strict 
rule  being  rigorously  applied. 

Brand's  original  method  consists  in  the  immersion  of  the 
patient  in  a  bath  of  60°  F.  for  fifteen  minutes,  repeated  every 
three  hours  so  long  as  the  temperature  is  102.2°  F.  by  the 
rectum.  During  the  bath  cold  water  is  applied  to  the  head 
and  the  surface  of  the  body  is  briskly  rubbed.  After  the 
bath  the  patient  is  dried,  wrapped  in  blankets,  and  given  a 
hot  alcoholic  drink  if  chilliness  is  apparent.  No  internal 
antipyretics  are  employed. 

Under  the  Brand  treatment  it  is  claimed  that  not  onlv  is 


40  MAXCAL    OF   THE   PRACTICE    OF  MEDICINE. 

the  temperature  reduced,  but  that  there  is  also  a  tonic  effect 
produced  on  the  circulatory  and  nervous  centres,  the 
intellect  becomes  clearer,  the  stupor  less  marked,  muscular 
twitchings  disappear,  and  insomnia  is  lessened,  the  patient 
frequently  falling  into  a  refreshing  sleep.  Complications  are 
rendered  more  infrequent,  and,  what  is  most  important, 
the  mortality  is  reduced  to  a  minimum.  Brand's  statistics 
show  but  twelve  deaths  in  1223  cases,  a  mortality  of  but  i 
per  cent.  Not  a  patient  died  who  came  under  treatment 
prior  to  the  fifth  day.  These  statistics,  however,  arc  taken 
from  German  militar}-  hospitals,  where  the  patients  are 
young,  robust,  and  are  treated  early.  Ordinarily,  under  this 
treatment  the  mortality  is  about  7  per  cent.  No  effect  is 
claimed  in  reducing  the  duration  of  the  disease  nor  in  less- 
ening the  liabilty  to  relapses.  The  contraindications  are 
intestinal  hemorrhage,  perforation  or  danger  of  perforation, 
and  peritonitis.  Bronchitis  and  pneumonia  do  not  prevent 
the  treatment. 

While  this  extreme  method  may  be  applicable  in  military 
hospitals  and  in  robust,  insensitive  patients,  its  rigorous 
employment  in  all  cases  has  decided  disadvantages  and 
requires  modification.  As  a  general  rule,  then,  the  modi- 
fied bath  must  be  employed,  the  temperature  being  80°  to 
90°  F.  at  the  commencement  and  being  gradually  reduced 
10°  F.  by  the  addition  of  cold  water.  This  bath  should 
be  given  whenever  the  temperature  is  102.5°  F.  or  over, 
provided  it  be  not  more  frequent  than  every  three  hours. 
Friction  of  the  body  and  affusion  of  the  head  should  be 
employed  in  all  cases. 

For  nervous,  sensitive  patients  who  are  in  mortal  dread 
of  such  a  modified  bath  the  wet  pack  may  be  employed. 
The  bedding  being  protected  by  a  rubber  blanket,  the 
patient  is  wrapped  in  wet  sheets  closely  applied  by  brisk- 
friction.  From  time  to  time  the  patient  is  sprinkled  with 
cool  water. 

The  most  simple  method  of  hydrotherapy  is  the  sponging 
of  the  body  with  water  or  with  water  and  alcohol.  If  done 
for  ten  or  fifteen  minutes  this  will  cause  a  slight  reduction 
in  temperature,  but  the  method  is  too  inefficient  to  be  of 


TV/' //Off)    FEVER.  41 

much  benefit  in  severe  cases.  The  slush  bath  may  be  used, 
the  bed  being  protected  by  a  rubber  sheet  raised  at  the 
sides,  so  as  to  form  a  trough,  in  which  the  patient  hes.  If 
skilfully  done,  five  gallons  of  water  may  be  used,  and  the 
results  seem  as  radical  as  the  bath,  without  many  of  its 
disadvantages. 

The  use  of  internal  antipyretics  is  attended  by  many  dis- 
advantages, and  is  less  frequently  employed  now  than  for- 
merly. While  the  temperature  may  be  reduced  by  these 
drugs,  there  is  also  a  depression  of  the  nervous  and  circula- 
tory centres,  so  that  stimulants  may  be  required  to  over- 
come the  effects  of  the  drugs.  The  actual  mortality  seems 
to  be  slightly  increased  by  their  use.  The  drugs  most  fre- 
quently employed  for  this  purpose  are  antipyrine  (gr.  x), 
phenacetine  (gr.  v),  and  antifebrine  (gr.  ij).  They  were 
formerly  given  in  much  larger  doses  than  at  present.  Qui- 
nine is  now  given,  not  to  reduce  temperature,  but  for  its 
tonic  effect.  Whatever  antipyretic  is  used  should  be  given 
in  small  doses  repeated  in  two  hours  if  necessary,  and  not 
too  great  a  fall  of  temperature  should  be  produced,  the  re- 
duction of  a  degree  or  a  degree  and  a  half  being  usually 
sufficient. 

The  pulse  should  be  watched  carefully,  with  special  regard 
to  its  weakness  rather  than  its  rapidity.  Alcohol  is  the  best 
stimulant,  in  the  form  of  whiskey  or  champagne,  and  when 
indicated  must  be  given  freely  until  its  effect  is  noticed,  even 
if  8  to  12  ounces  of  whiskey  be  given  in  the  twenty-four 
hours.  Strychnine  may  be  combined  with  the  alcohol,  and 
is  of  service.  Digitalis  may  also  be  employed.  In  cases 
where  there  is  a  rapid  feeble  pulse  with  marked  septic 
symptoms,  large  rectal  enemata  and  of  intestinal  disinfect- 
ants often  are  of  benefit. 

Vomiting  is  best  treated  by  regulating  the  diet.  Bismuth 
and  oxalate  of  cerium  are  occasionally  serviceable.  If  vom- 
iting seems  to  be  due  to  the  tympanites,  the  latter  condition 
should  be  treated.  In  severe  cases  rectal  feeding  may  have 
to  be  resorted  to. 

For  the  diarrlicea  opium  by  the  mouth  or  the  rectum, 
with  the  addition  of  the  ordinary  astringent  drugs,  is  to  be 


42  MAXi'AL    OF   TN£   rRACTICE    OF  MEDICINE. 

given.  The  stools  should  be  examined  to  sec  that  the 
diarrhoea  is  not  caused  by  undigested  curds. 

Constipation  is  to  be  treated  in  the  first  week  by  saline 
laxatives  or  by  castor  oil.  Later  in  the  disease  enemata  are 
preferable,  so  that  the  bowel  is  emptied  every  second  day. 

For  the  tympanites  turpentine  stupes  or  5-minim  doses  of 
turpentine  in  capsule  constitute  the  best  treatment.  Intes- 
tinal antiseptics,  as  salol,  ^-naphthol,  or  creosote,  may  be  of 
service,  while  the  insertion  of  a  soft  rectal  tube  may  afford 
relief. 

For  JicniorrJiagcs  the  patient  should  be  kept  absolutely 
quiet,  opium  in  full  doses  being  given.  The  use  of  internal 
astringents  does  not  seem  to  do  good.  Applications  of  heat 
to  the  abdomen  may  be  employed.  Ice  should  not  be  used, 
as  it  increases  intestinal  peristalsis.  The  diet  should  be 
restricted,  although  the  patient  may  be  given  acid  drinks 
and  cracked  ice.  In  case  of  severe  hemorrhage  external 
warmth  and  stimulants  should  be  used.  Subcutaneous  in- 
jections of  warm  sterilized  saline  solutions  may  be  given. 

The  treatment  of  perforation  is  that,  in  the  first  place, 
of  collapse — by  warmth  to  the  body  and  free  stimulation, 
while  opium  should  be  given  in  full  doses.  Should  the 
perforation  occur  in  a  robust  person  or  during  convalescence, 
the  question  of  laparotomy  and  closure  of  the  perforation 
should  be  considered. 

Peritonitis  is  to  be  treated  by  the  cold  abdominal  coil  and 
by  opium  in  full  doses.  In  selected  cases  laparotomy  and 
drainage  may  be  resorted  to. 

The  nervous  symptoms  are  best  controlled  by  the  hydro- 
pathic treatment,  which,  acting  as  a  tonic  on  the  nervous 
centres,  reduces  the  restlessness,  allays  the  delirium,  and 
promotes  sleep.  Where  this  treatment  can  be  employed 
drug  sedatives  are  seldom  needed.  Where  drugs  are  needed 
phenacetine  (gr.  v,  q.  3  h.)  will  relieve  the  headache  and 
restlessness,  sulphonal  (gr.  x-xx)  or  chloralamide  (gr.  x-xv) 
will  promote  sleep.  In  severer  cases  opium  may  be  neces- 
sary. 

Complications  are  to  be  treated  on  general  principles. 

Treatment  of  convalescence  is  trying  to  physician   and  to 


TVrilUS  FEVER.  43 

patient  alike.  The  greatest  care  should  be  exercised  in 
the  management  of  the  diet,  as  the  patients  are  ravenously 
hungry  and  clamor  for  food.  The  patient  should  be  kept 
in  bed  for  five  days  after  the  temperature  is  normal,  and  on 
a  fluid  diet — not  necessarily,  however,  on  milk.  No  solid 
food  should  be  given  for  at  least  ten  days.  At  the  end  of 
this  time  one  solid  meal  may  be  given  in  the  middle  of  the 
day,  of  chop  or  mutton  with  a  baked  potato,  and  afterward 
a  gradual  change  to  three  meals  a  day  may  be  allowed. 
There  are  cases  where  the  evening  temperature  remains 
irregularly  high.  These  cases  are  benefited  by  quinine 
and  solid  food.  During  convalescence  attention  should  be 
given  to  the  digestion  and  the  bowels,  and  tonics  should  be 
administered.  A  change  of  air  is  to  be  recommended,  and 
patients  should  not  be  allowed  to  return  too  soon  to 
business  and  daily  cares.  The  results  of  serum-therapy  in 
typhoid  fever  have  not  seemed  to  justify  its  continuance  as 
a  means  of  treatment.  The  preventive  inoculations  of 
typhoid  serum  a-re  now  being  practised  on  a  large  scale  in 
the  English  army,  but  the  experiment  is  of  too  recent  a 
date  to  enable  any  conclusions  to  be  drawn  as  to  its  efficacy. 
The  recrudescences  are  to  be  treated  by  a  milk  diet  and 
rest  in  bed  while  the  fever  remains  high.  The  treatment  of 
a  relapse  does  not  differ  from  that  of  the  original  attack. 

TYPHUS  FEVER. 

Definition  and  Synonyms. — Typhus  fever  is  an  acute 
contagious  disease  with  an  acute  onset,  a  characteristic 
eruption,  and  a  febrile  movement  of  about  two  weeks'  dura- 
tion. Synonyms:  Cerebral  typhus  ;  Exanthematic  typhus; 
Spotted,  Camp,  Jail,  or  Ship  fever. 

Etiology. — Typhus  fever  is  endemic  in  England,  Ireland, 
and  Russia,  and  to  a  less  extent  in  Poland,  Galicia,  and  cer- 
tain parts  of  Southeast  Europe.  A  i^w  cases  occur  every 
year  in  New  York  and  Philadelphia.  From  time  to  time 
the  disease  occurs  in  other  places  in  epidemics.  These  epi- 
demics have  usually  followed  wars  or  famines,  the  disease 
being  regularly  favored  by  the  overcrowding  of  people  in 
jails,  houses,  or  camps,  by  poor  hygiene,  by  starvation,  and 


44  MAXL'AL    OF  THE   PRACTICE    OF  MEDICINE. 

by  filth.  It  never  arises  spontaneously,  but  al\va)-s  from 
soniQ  previous  case.  It  is  one  of  the  most  highly  conta- 
gious diseases  known,  being  equally  virulent  throughout 
its  course.  The  poison  of  the  disease  has  not  as  yet  been 
demonstrated,  although  it  is  known  to  be  given  off  from  the 
bodies  of  the  sick  and  the  dead,  to  be  carried  in  the  air, 
and  to  be  retained  in  bedding,  clothes,  carpets,  etc.  for  a 
considerable  time,  so  that  the  poison  is  conveyed  not  only 
from  person  to  person,  but  also  by  clothing  and  bed-rooms. 
But  a  very  few  persons  are  exempt  if  they  be  sufficiently 
exposed,  and  the  more  prolonged  and  concentrated  the 
exposure  the  more  certainly  will  they  be  attacked.  One 
attack  usually  procures  immunity.  While  no  age  is  exempt, 
the  majority  of  cases  occur  between  the  fifteenth  and  thir- 
tieth years. 

Pathology. — The  eruption  is  the  only  characteristic 
lesion.  After  death  there  may  be  found  a  number  of  mor- 
bid conditions  common  to  any  of  the  severe  infectious 
diseases. 

Symptoms. — The  period  of  incnbation  is  about  twelve 
days,  although  cases  may  develop  as  early  as  twelve  hours 
or  as  late  as  three  weeks  after  exposure. 

The  onset  is  abrupt,  although  in  some  cases  it  is  preceded 
for  a  few  days  by  malaise  and  frontal  headache.  The  initial 
symptoms  are  a  chill,  a  rise  of  temperature,  headache,  and 
prostration.  The  chill,  which  is  usually  sharp  and  severe, 
may  be  repeated. 

The  temperature  rises  suddenly,  attaining  its  maximum 
from  the  third  to  the  fifth  day,  reaching  103°  F.  in  mild  and 
105°  F.  in  severe  cases.  During  the  first  week  the  tempera- 
ture remains  steadily  continuous,  becoming  somewhat  higher 
in  the  second  week,  but  with  morning  remissions.  In  bad 
cases  there  may  be  hyperpyrexia.  From  the  twelfth  to  the 
fourteenth  day  comes  the  crisis,  the  temperature  falling 
rapidly — sometimes  a  drop  of  4°  to  5°  F.  in  a  i^^  hours, 
although  usually  it  takes  twenty-four  to  forty-eight  hours 
before  the  temperature  reaches  the  normal ;  this  fall  of 
temperature  is  accompanied  by  an  improvement  of  all  the 


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symptoms,  the  patient  entering  at  once  upon  the  period  of 
convalescence. 

The  headache  is  usually  frontal  and  is  very  severe — more 
so  than  in  any  other  disease  except  meningitis.  With  the 
headache  are  pains  in  the  back  and  bones  and  soreness  of 
the  muscles. 

Prostration  is  marked  from  the  onset,  the  patient  taking 
to  bed  from  vi^eakness  within  a  few  hours.  It  may  be  so 
severe  and  sudden  that  the  patient  will  fall  in  the  street 
without  previous  warning. 

Nausea  and  vomiting  are  commonly  present,  and  may  be 
distressing.  The  tongue  is  heavily  coated  in  the  first  week, 
later  having  a  tendency  to  become  dry  and  brown,  with 
sordes  on  the  teeth  and  gums.  The  bowels  are  usually  con- 
stipated, although  there  may  be  diarrhoea. 

The  pulse  is  rapid  and  full,  being  between  lOO  and  120; 
it  becomes  more  rapid  and  feeble  during  the  second  week. 
Marked  slowness  of  the  pulse  may  be  observed  at  any  time 
of  the  disease  and  may  continue  into  convalescence.  A 
drop  in  the  pulse  without  improvement  in  other  symptoms 
is  not  a  good  sign.  The  urine  usually  shows  the  presence 
of  albumin  and  casts  in  moderate  amounts  from  an  acute 
degeneration  of  the  kidney.  More  rarely  there  are  present 
the  urinary  changes  of  acute  exudative  nephritis. 

Early  in  the  disease  there  is  a  look  about  the  patient 
which  is  often  of  diagnostic  value.  The  face  assumes  a 
dusky  flush,  the  conjunctivae  are  injected,  and  the  expres- 
sion is  dull  and  vacant,  the  whole  appearance  suggesting 
marked  intoxication.     The  pupils  are  contracted. 

The  characteristic  eruption  appears  from  the  third  to  the 
fifth  day,  although  it  may  be  seen  as  early  as  the  second 
and  as  late  as  the  seventh  day.  It  consists  of  small,  irreg- 
ularly rounded  spots,  of  a  dirty-pink  color,  appearing  first 
on  the  abdomen  and  chest,  and  becoming  more  general, 
although  rarely  seen  on  the  face.  It  appears  in  one  crop, 
and  is  all  out  in  from  two  to  five  days,  lasting  from  seven  to 
ten  days  and  then  slowly  fading.  It  is  usually  abundant, 
though  in  some  cases  it  may  be  scanty.  At  first  the  spots 
are  slightly  elevated  and  disappear  on  pressure,  but  after 


46  MAXi'AL    OF   THE   PRACTICE    OF  MEDICINE. 

several  days  they  become  petechial  and  more  perma- 
nent, remaining  after  pressure.  They  have  no  well-defined 
margin.  In  children  the  eruption  resembles  that  of  measles, 
and  from  the  mottled  appearance  given  by  it  to  the  skin  the 
eruption  has  been  termed  the  Diulbeny  rash.  In  some 
cases  there  is  added  a  diffused,  deep  mottling  of  the  skin 
with  large  purplish  blotches ;  in  others  there  are  hemor- 
rhagic spots  or  a  general  erythema.  These  manifestations 
are  not  characteristic  and  are  inconstant. 

Cerebral  symptoms  are  marked  and  appear  early.  The 
headache,  so  marked  at  the  onset,  usually  becomes  masked 
by  other  nervous  s\'mptoms  by  the  end  of  the  first  week. 
Delirium  is  a  fairly  constant  symptom.  In  very  severe 
cases  it  may  come  on  in  the  first  twenty-four  hours  of  the 
disease  in  the  form  of  an  acute  mania.  In  less  severe  cases 
it  is  not  seen  until  the  end  of  the  first  week.  It  may  then 
be  only  a  mild  delirium  at  night,  or  it  may  be  more  decided, 
persisting  throughout  the  day.  This  latter  form  is  often 
associated  with  delusions  which  at  any  time  may  render  the 
patient  violent.  In  severe  cases,  during  the  second  week 
there  may  be  observed  alternately  with  the  delirium  a  form 
of  deep  stupor  known  as  "coma  vigil,"  in  which  the  eyes 
are  wide  open  but  the  patient  is  unconscious. 

Deafness  may  appear  in  the  second  week  without  assign- 
able cause,  but  from  it  the  patient  usually  recovers. 

If  the  case  is  to  end  fatally,  the  temperature  rises,  often  to 
io6°  or  io8°  F.  before  death,  the  delirium  and  stupor  be- 
come more  decided,  there  may  be  retention  of  urine  and 
incontinence  of  feces,  the  pulse  becomes  more  rapid  and 
feeble,  and  death  occurs  from  exhaustion  from  the  toxaemia. 
Should  the  patient  survive  until  the  third  week,  death  usu- 
ally results  from  a  complicating  pneumonia. 

If  the  case  is  to  recover,  on  about  the  fourteenth  day  there 
is  a  decided  fall  in  the  temperature,  the  patient  frequently 
falling  into  a  refreshing  sleep  from  which  he  awakes  weak 
but  convalescent.  In  some  cases  this  crisis  occurs  as  early 
as  the  seventh  day,  or  at  this  time  there  may  be  a  decided 
remission  in  the  temperature,  practically  an  abortive  crisis. 


TYPHUS  J' EVER.  47 

which  is  to  be  considered  a  favorable  omen.  In  other  cases 
the  crisis  may  be  deferred  as  late  as  the  twenty-first  day. 

In  some  epidemics  light  cases  are  seen,  running  a  mild 
course,  with  a  temperature  usually  under  102°  F.,  with  but 
moderate  cerebral  symptoms.  The  crisis  usually  occurs 
between  the  seventh  and  the  twelfth  day.  Occasionally 
there  are  observed  in  severe  epidemics  malignant  cases  in 
which  the  patient  is  overwhelmed  by  the  virulence  of  the 
disease.  There  are  rapidly  developed  a  sudden  tempera- 
ture, usually  high,  progressive  heart  failure,  stupor,  and 
coma,  and  death  may  result  in  from  twelve  to  twenty-four 
hours  or  within  two  or  three  days.  In  these  cases  no 
regular  eruption  is  seen,  but  ecchymoses  and  hemorrhagic 
spots  are  irregularly  developed. 

Complications. — There  may  be  broncho-pneumonia, 
which  in  rare  cases  is  complicated  by  gangrene  of  the 
lung.  Gangrene  of  the  extremities  or  cancrum  oris  in 
children  has  been  observed.  Meningitis  is  rare  and  is 
always  fatal.  Abscesses  in  the  skin  and  the  joints  may 
occur,  and  suppurative  parotitis  is  not  uncommon.  There 
may  be  hemorrhages  into  the  skin  or  from  any  of  the 
mucous  membranes  accompanying  serious  cases.  Throm- 
bosis of  large  veins  or  of  cerebral  sinuses  may  occur. 

Convalescence  is  usually  rapid  at  first,  although  it  is 
months  before  it  is  complete.  There  are  no  relapses.  The 
patient  may  be  left  dull  and  feeble-minded,  from  which  con- 
dition the  recovery  is  gradual.  A  few  patients  develop  acute 
mania  in  convalescence,  but  the  ultimate  prognosis  is  gen- 
erally good.  Paralysis  from  post-febrile  neuritis  is  not 
uncommon. 

Prognosis. — The  mortality  is  from  10  to  20  per  cent., 
varying  with  the  nature  of  the  epidemic,  the  previous  con- 
dition, and  the  age  of  the  patient.  The  disease  is  rarely 
fatal  in  young  subjects,  but  is  very  serious  in  those  past 
adult  life.  Complicating  inflammations  alter  the  prognosis 
according  to  their  nature. 

Treatment. — The  patient  should  be  isolated  thoroughly 
from  the  start.  To  lessen  the  danger  of  contagion  to  nurse 
and  to  physician,  the  windows    must  be  opened   freely  to 


48  MANUAL    OF  THE   PRACTICE    OF  MEDICINE. 

admit  fresh  air.  If  possible,  the  patient  should  occupy  two 
rooms,  one  by  day  and  one  by  night,  the  freest  ventilation 
thus  being  afforded.  In  epidemics  the  cases  are  best  treated 
in  tents,  the  patients  being  protected  in  winter  by  extra 
bedding.  This  fresh-air  treatment  is  not  only  a  prophylactic 
measure,  but  seems  also  to  lessen  the  actual  mortality. 
Windows  should  be  protected  by  bars  in  case  mania 
dev^elops. 

There  is  no  specific  treatment  for  the  disease.  Formerly 
mineral  acids  were  so  considered,  but  they  are  given  now 
only  because  they  afford  a  pleasant  acidulated  drink  and 
do  no  harm. 

The  treatment,  then,  is  entirely  symptomatic.  The  tem- 
perature is  best  treated  by  hydrotherapy,  as  in  typhoid  fever, 
the  bath  being  given  as  soon  as  the  temperature  reaches 
103°  F.  Internal  antipyretics  should  be  avoided  if  possible, 
because  of  their  depressing  effect.  Alcohol  in  some  form 
is  demanded  in  almost  all  cases,  and  it  may  be  given  in 
large  doses  until  a  good  effect  is  observed  on  the  heart's 
action  :  10  to  20  ounces  of  whiskey  may  be  required  in  the 
twenty-four  hours.  The  delirium  and  headache  should  be 
treated  by  sedatives  combined  with  hydrotherapy.  Other 
symptoms  should  be  treated  on  general  principles. 

RELAPSING  FEVER. 

Definition  and  Synonyms. — Relapsing  fever  is  an  acute 
infectious,  contagious  disease  due  to  a  spirillum,  and  cha- 
racterized by  a  febrile  paroxysm  of  about  six  days'  duration, 
followed  usually  by  one  or  more  similar  recurrences  at  reg- 
ular intervals.  Synonyms:  Famine  fever;  Spirillum  fever ; 
Relapsing  typhus. 

Etiology. — The  disease  is  a  rare  one,  occurring  in  epi- 
demics which  last  but  a  short  time  and  then  die  out,  leaving, 
except  in  very  rare  exceptions,  no  endemic  cases.  Epi- 
demics were  seen  in  Philadelphia  in  1844,  and  in  New  York 
and  Philadelphia  in  1847  and  1869.  The  last  epidemic  of 
any  importance  was  in  Russia  in  1886. 

Epidemics  have  frequently  been  associated  with  those  of 
typhus  fever,  the  spread  of  both  diseases  being  favored  by 


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RELAPSING   FKVKR.  49 

filth,  by  famine,  and  by  overcrowding  of  people.  Neither 
age,  sex,  nor  cHmate  exerts  any  influence  upon  the  epi- 
demics. 

The  disease  is  actively  contagious,  not  only  by  personal 
contact,  but  also  through  clothes  and  bedding  and  through 
the  medium  of  a  third  person.  One  attack  does  not  secure 
immunity  from  subsequent  attacks. 

The  exciting  cause  is  infection  by  a  spirillum  or  spiro- 
chsete,  first  described  in  1873  by  Obermeier.  The  spirillum 
is  a  slender  spiral  filament  endowed  with  motion,  its  length 
being  three  to  six  times  as  long  as  the  diameter  of  a  red 
blood-cell.  It  is  present  in  the  blood,  but  only  during  the 
febrile  paroxysm.  Before  the  crisis  and  in  the  intervals 
between  the  paroxysms  only  round  glistening  bodies  are 
seen,  which  bodies  are  supposed  to  be  the  spores.  Inocu- 
lations of  the  spirillum  into  man  and  monkeys  have  repro- 
duced the  disease. 

Patholog-y. — There  are  no  lesions  characteristic  of  the 
disease.  The  spleen  is  large  and  soft  and  may  rupture. 
There  are  parenchymatous  changes  in  the  liver,  the  kidneys, 
and  the  heart-muscle.  There  may  be  internal  hemorrhages. 
The  tissues  may  be  jaundiced. 

Symptoms. — Incubation  may  be  short,  the  attack  devel- 
oping a  few  hours  after  exposure.  Ordinarily  the  period  is 
from  five  to  seven  days,  during  which  time  there  are  no 
symptoms.  The  disease  begins  abruptly  with  a  chill,  fol- 
lowed by  a  rapid  rise  of  temperature,  running  to  103°  to 
107°  F.  within  twenty-four  hours.  There  are  severe  and 
distressing  pains  in  the  head,  back,  and  bones.  Prostration 
is  well  marked  at  the  onset,  the  patient  taking  to  his  bed 
at  once.  The  pulse  is  full  and  varies  between  no  and  130. 
There  is  usually  nausea ;  there  may  be  severe  vomiting,  and 
in  some  cases  vomiting  of  blood.  In  severe  cases  there 
may  be  delirium.  Convulsions  may  be  the  first  symptom 
in  young  subjects. 

The  liver  and  spleen  are  regularly  enlarged  and  tender. 
Blood-examination  shows  the  spirilla  in  active  movement 
among  the  red  blood-cells.  Jaundice  may  be  present  in  the 
4 


50  MJXr.lL    OF   THE   PRACTICE    OF  MEDICIXE. 

attack  or  in  an\'  of  the  relapses.  It  belongs  to  the  severer 
forms  of  the  disease. 

There  is  no  characteristic  eruption,  but  in  certain  cases 
there  may  appear  small  reddish  spots  somewhat  resembling 
the  eruption  of  typhus  fever,  or  there  may  be  petechial  spots. 
The  urine  contains  a  slight  amount  of  albumin  and  casts 
from  parenchymatous  degeneration. 

While  the  symptoms  are  at  their  height  the  paroxysm 
suddenly  ceases,  the  temperature  suddenly  falling  by  crisis, 
and  the  patient  is  left  weak  but  convalescent.  This  remark- 
able crisis  usually  occurs  between  the  fifth  and  the  seventh 
day,  although  it  may  occur  as  early  as  the  third  or  as  late 
as  the  tenth  day.  This  abrupt  crisis,  which  is  always  a 
time  of  danger,  may  be  accompanied  by  profuse  sweating  or 
exhausting  diarrhoea.  In  some  cases  there  may  be  collapse, 
or  hemorrhages  from  the  stomach,  the  intestines,  or  the 
kidneys. 

After  such  an  attack  the  patient  may  pass  on  to  recovery, 
but  in  the  majority  of  cases,  after  an  interval  of  about  seven 
days  (the  limit  is  from  five  to  twenty  days),  the  patient  is  again 
suddenly  seized  with  a  repetition  of  all  the  symptoms  of  the 
first  attack,  the  spirilla  again  becoming  present  in  the  blood. 
This  second  attack  usually  is  less  prolonged  than  the  first, 
lasting  about  three  days,  although  it  may  last  only  one  day 
or  be  prolonged  for  a  week.  This  attack  terminates  by  crisis 
as  does  the  first.  The  patient  ma}"-  now  pass  on  to  complete 
recovery,  or  there  may  be  a  series  of  these  relapses  (up  to 
five  or  six),  these  subsequent  attacks  becoming  shorter  and 
less  severe. 

Complications. — There  may  be  hypostatic  congestion  of 
the  lungs  or  broncho-pneumonia.  Laryngitis  and  oedema 
of  the  glottis  may  occur.  There  may  be  rupture  of  the 
spleen  with  internal  hemorrhage  and  peritonitis.  Nephri- 
tis is  of  rare  occurrence.  In  severe  cases  there  may  be 
hemorrhages  from  the  stomach,  the  intestines,  or  the 
kidneys. 

Convalescence  is  apt  to  be  slow  and  tedious,  especially 
if  there  has  been  a  scries  of  relapses.     There  may  be  paral- 


SMALL-POX.  51 

yses  of  groups  of  muscles  from  post-febrile  neuritis.  There 
may  be  ophthalmia  with  loss  of  sight. 

The  progTiosis  is  good.  The  mortality  is  from  2  to  4 
per  cent. 

Treatment. — There  is  no  specific  treatment.  Cases  are 
to  be  isolated  thoroughly,  and  clothing,  etc.  disinfected,  to 
prevent  the  spread  of  the  disease.  The  treatment  is  on 
general  principles.  It  is  especially  important  that  the 
patient  should  be  well  watched  at  the  time  of  crisis  for  indi- 
cations of  heart  failure.  The  diarrhoea  which  often  occurs 
at  this  time  should  be  treated  promptly.  After  the  crisis 
the  patient  should  be  kept  in  bed  for  at  least  a  week  and  on 
fluid  food. 

SMALL-POX. 

Definition  and  Synonym. — Small-pox  is  an  acute  infec- 
tious, contagious  disease  with  marked  constitutional  symp- 
toms and  a  characteristic  eruption.     Synonym :  Variola. 

Etiology. — This  disease  was  known  to  the  ancients  and 
was  fully  described  by  the  older  writers.  Formerly  it 
occurred  in  devastating  plagues,  but  since  the  discovery  of 
vaccination  it  has  become  less  and  less  frequent,  so  that 
cases  of  true  small-pox  are  but  rarely  seen.  With  universal 
vaccination  the  disease  bids  fair  to  become  extinct. 

Small-pox  is  actively  contagious  throughout  its  entire 
course.  The  contagion,  which  is  conveyed  by  personal 
contact  or  by  the  medium  of  a  third  person,  emanates  from 
the  bodies  of  the  sick  and  the  dead,  floats  in  the  air,  and 
can  remain  in  bedding,  clothes,  cabs,  and  rooms  for  months 
and  years  without  losing  its  virulent  properties.  It  is 
inoculable  by  the  contents  of  the  vesicles  and  pustules  and 
by  the  blood  of  the  sick,  and  is  most  actively  conveyed  by 
the  scales  and  crusts  thrown  off  by  the  patients ;  these 
scales  float  in  the  air  as  a  fine  dust,  and  in  this  way  may  be 
carried  long  distances. 

The  exact  nature  of  the  contagion  has  nev^er  definitely 
been  determined.  Micro-organisms  have  been  found  in  the 
contents  of  the  vesicles  and  pustules,  but  these  micro-organ- 
isms are  common  to  all  suppurative  processes. 


52  MAXL'AL    OF  THE   PRACTICE    OF  MEDIC L\E. 

■  Susceptibility  to  the  disease  is  almost  universal  except 
among  those  protected  by  vaccination  or  by  a  previous 
attack.  No  age  is  exempt,  the  disease  even  attacking  the 
foetus  in  ntcro.  Negroes  are  more  susceptible  than  other 
races,  though  this  may  be  due  to  their  neglect  of  vaccina- 
tion. Vaccination  properly  performed  procures  immunity, 
as  does  a  previous  attack,  although  in  rare  cases  the  immu- 
nity may  not  extend  beyond  a  term  of  years  (five  to  fifteen). 

The  disease  exists  in  nearly  all  countries  as  an  endemic 
disease,  a  certain  number  of  cases  occurring  every  year. 
Under  favoring  circumstances  it  assumes  from  time  to  time 
epidemic  proportions.  These  epidemics  are  terribly  devas- 
tating should  they  occur  among  aboriginal  races  where 
small-pox  has  not  previously  existed. 

Pathology. — Aside  from  the  eruption  there  are  no  char- 
acteristic lesions.  There  may  be  found  the  enlarged  spleen 
and  the  parenchymatous  changes  in  the  liver,  the  kidneys, 
and  the  heart-muscle  that  are  present  in  all  severe  infectious 
diseases.     Severe  cases  may  reveal  internal  hemorrhages. 

Symptoms. — The  period  of  incnhation  is  usually  from 
ten  to  fourteen  days,  during  which  time  there  are  no  symp- 
ton]s. 

Five  forms  of  the  disease  are  described:  i.  The  discrete 
form  ;  2.  The  confluent  form  ;  3.  The  hemorrhagic  form ; 
4.  The  malignant  form  ;  5.  Varioloid,  or  small-pox  modified 
by  vaccination  or  by  a  previous  attack. 

I.  The  Discrete  Form. — The  symptoms  are  described  as 
occurring  in  two  stages. 

{a)  Stage  of  Invasion. — The  onset  is  sudden,  being 
ushered  in  by  a  chill  which  is  violent  and  severe  and  which 
may  be  repeated.  The  temperature  rapidly  rises,  reaching 
103°  or  104°  F.  in  twenty- four  hours.  There  is  severe 
headache,  usually  frontal,  which  is  marked  and  character- 
istic, and  which  lasts  throughout  this  stage  with  undimin- 
ished severity.  With  the  headache  there  are  regularly  severe 
pains  in  the  bones,  muscles,  and  loins.  Especially  charac- 
teristic is  an  excruciating  pain  in  the  sacrum  that  is  present 
in  about  half  the  cases.  The  severity  of  the  pains  gives  no 
clue  to  the  future  severity  of  the  attack.     While  the  head- 


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SMALL- POX.  53 

ache  and  backache  are  common  to  the  onset  of  all  severe 
infections,  there  is  no  disease  in  which  they  are  so  marked 
as  in  small-pox,  and  their  occurrence  should  excite  appre- 
hension, especially  during  an  epidemic  or  occurring  in  an 
unprotected  patient  who  has  been  exposed  to  the  disease. 

Vomiting  is  usually  severe  and  distressing,  and  prostra- 
tion is  an  early  symptom,  the  patient  taking  to  his  bed  at 
the  very  onset.  The  pulse  is  rapid  and  full,  increasing  in 
rapidity  with  the  rise  of  the  fever,  and  becoming  weak  in 
proportion  to  the  severity  of  the  disease.  Nervous  symp- 
toms belong  to  the  severer  cases.  There  may  be  active 
delirium,  especially  in  patients  with  high  fever.  Convul- 
sions in  place  of  the  chill  may  initiate  the  disease  in  chil- 
dren. There  are  usually  considerable  restlessness  and  gen- 
eral apprehension.  The  eyes  are  bright ;  the  skin  is  hot 
and  dry ;  the  spleen  is  enlarged,  and  albumin  and  casts  may 
be  found  in  the  urine  in  small  amount. 

There  is  no  characteristic  eruption  in  the  stage  of  inva- 
sion, although  an  initial  rash  may  be  observed.  This  rash 
appears  with  more  frequency  in  some  epidemics  than  in 
others,  as  a  rule,  however,  appearing  in  from  lO  to  15  per 
cent,  of  all  cases.  It  consists  of  an  erythema  which  may 
be  diffuse  or  macular,  closely  resembling  the  eruption  either 
of  scarlet  fever  or  of  measles,  although  it  differs  from  both 
in  its  localization.  It  is  often  associated  with  small  hemor- 
rhagic spots.  This  initial  erythema  occurs  on  the  second 
day,  and  it  appears  usuall}^  on  the  hypogastrium,  the  inner 
surfaces  of  the  thighs  and  opposing  surfaces  of  the  side  of 
the  chest,  and  the  inner  side  of  the  arms — regions  which 
are  usually  exempt  from  the  regular  eruption.  This  early 
rash  lasts  but  a  short  time  and  then  fades  away. 

The  stage  of  invasion  lasts  regularly  three  days,  during 
which  time  the  symptoms  continue,  the  temperature  usually 
becoming  somewhat  higher,  so  that  it  may  reach  105°  to 
107°  F. 

{b)  Stage  of  Eniption. — The  eruption  is  peculiar  in  that 
it  passes  through  successive  stages  in  development,  becom- 
ing in  turn  macules,  papules,  vesicles,  and  pustules.  Begin- 
ning on  the  fourth  day  of  the  disease,  there  appear  small 


54  MAXr.lI.    OF   THE   PRACTICE    OF  MEDICIXE. 

round,  slightly  raised  spots,  involving  first  the  face,  the  edge 
of  the- hairy  scalp,  and  the  backs  of  the  wrists,  and  extending 
within  twenty-four  hours  over  the  trunk,  the  arms,  and,  last 
of  all,  the  legs.  On  the  second  day  of  the  eruption  the  spots 
become  papules  which  are  hard  to  the  feel,  suggesting  bird- 
shot  imbedded  in  the  skin.  By  the  third  day  the  papules 
change  to  vesicles  which  have  each  a  depressed  umbilicated 
centre  without  any  tendency  to  rupture.  Should  these 
vesicles  be  pricked,  they  do  not  completely  discharge  their 
contents.  Vesiculation  is  complete  on  the  sixth  day ;  the 
vesicles  then  become  pustular.  The  central  umbilication 
usually  disappears,  so  that  there  result  pustules  each  with 
a  rounded  summit  surrounded  by  a  zone  or  areola  of 
inflamed  and  swollen  skin  which  burns  and  itches  and 
causes  the  feeling  of  distressing  tension.  The  face  is  now 
strikingly  swollen  and  disfigured ;  the  eyelids  are  closed 
by  oedema.  In  severe  cases  the  skin  between  the  pustules 
becomes  diffusely  inflamed,  adding  to  the  distress  and  dis- 
figurement of  the  patient.  The  pustules  are  completely 
developed  on  the  eighth  or  ninth  day  of  the  eruption,  and 
after  continuing  for  about  three  days  begin  to  dry  up  and 
to  form  scabs  and  crusts  w^iich,  falling  off,  leave  pigmented 
spots  that  persist  for  months.  If  the  ctiks  vera  has  been 
involved  by  the  pustules,  permanent  depressed  white  cica- 
trices must  necessarily  result.  The  desiccation  requires  a 
week  or  ten  days  for  its  completion,  and  it  is  attended  by 
much  itching. 

There  are  usually  similar  eruptions  in  various  mucous 
membranes,  especially  those  of  the  mouth,  pharynx,  nasal 
cavities,  larynx,  and  trachea,  and  less  frequently  of  the 
upper  portion  of  the  oesophagus,  the  bronchi,  the  conjunc- 
tiva, the  vagina,  and  the  rectum.  When  the  eruption 
appears  on  mucous  membranes,  it  is  modified  by  the  heat, 
moisture,  and  friction  of  the  parts,  and,  instead  of  pustules 
being  formed,  the  vesicles  become  macerated  and  form 
ulcers,  more  or  less  deep,  which  may  become  confluent. 

As  the  eruption  appears  the  temperature  suddenly  falls 
— not,  however,  quite  to  the  normal,  but  still  remaining  a 
little  high.      The  constitutional   symptoms    remit  in   their 


SMALL- POX.  55 

severity,  especially  the  headache  and  backache,  so  that  the 
patient  feels  quite  comfortable,  and  often  is  able  to  leave 
the  house  and  to  apply  for  treatment  at  a  hospital  or  a  dis- 
pensary. 

The  amelioration  of  the  symptoms  continues  until  the 
pustular  stage  is  reached,  when  there  is  developed  a  rise 
of  temperature  to  ioi°  to  105°  F.  with  a  return  of  all  the 
symptoms.  This  fever,  which  is  termed  the  secondary  or 
suppurative  fever,  is  often  remittent.  During  this  stage 
there  may  be  active  delirium,  so  that  the  patient  may  do 
himself  or  his  attendants  bodily  injury.  The  distress  during 
this  period  from  the  itching,  tension,  and  burning  of  the 
skin  is  almost  unbearable.  The  patient  is  disfigured  and 
often  is  hardly  recognizable. 

The  period  of  secondary  fever  lasts  for  from  three 
to  eight  days,  and  then  as  desiccation  is  established  the 
temperature  gradually  falls  and  convalescence  is  begun. 
The  hair  frequently  falls  out,  and  in  some  cases  does  not 
grow  again. 

2.  TJie  Confluent  Form. — Here  the  typical  symptoms  are 
present  in  the  most  complete  development.  The  stage  of 
invasion  is  short,  lasting  but  two  days  as  a  rule.  It  is  also 
severe,  the  fever  being  high,  with  pronounced  headache  and 
frequently  with  active  delirium.  There  is  no  period  of 
cessation  with  the  appearance  of  the  eruption,  although  the 
symptoms  may  remit  slightly  in  their  severity. 

The  eruption  is  profuse,  the  pustules  becoming  confluent, 
so  that  whole  areas,  especially  of  the  face  and  hands,  are 
converted  into  suppurating  blebs.  The  patient  is  unrecog- 
nizable, the  distress  is  extreme,  and  the  stench  is  penetrating 
and  intense. 

The  mucous  membranes  are  usually  extensively  involved. 
The  suppurative  fever  is  apt  to  run  high  and  is  attended  by 
symptoms  of  a  septic  character — irregular  chills  followed  by 
exacerbations  of  fever,  rapid  and  feeble  pulse,  diarrhoea,  and 
extreme  prostration  with  a  low  muttering  delirium  which 
at  times  may  assume  an  active  form.  In  this  septic  condi- 
tion the  patient  may  die.      Desiccation  continues  into  the 


56  MAXi'AL    OF   THE   PRACTICE    OF  MEDICINE. 

third  and  fourth  weeks,  during  which  time  the  symptoms 
of  the  secondary  fever  persist  with  diminishing  intensity. 

3.  The  Hcmorrliagii  Form. — This  form  is  characterized  by 
hemorrhages  occurring  in  the  pustules  and  the  skin  and 
from  any  of  the  free  mucous  surfaces — from  the  nose,  mouth, 
lungs,  stomach,  intestines,  kidneys,  or  uterus.  This  form 
of  small-pox  ma\'  occur  in  weak,  debilitated  subjects,  or 
the  hemorrhages  may  complicate  the  severer  forms  of  the 
disease. 

4.  TJie  Malig)iant  Form. — The  invasion  in  malignant  cases 
is  characterized  by  extreme  prostration  and  enfeebled  heart- 
action,  the  initial  rise  of  temperature  not  being  high.  In 
from  eighteen  to  thirty-six  hours  there  appears  an  erythema 
(resembling  scarlet  fever  with  large  hemorrhagic  blotches) 
which  occurs  extensively  over  the  body,  especially  the 
abdomen  and  thighs.  There  are  frequently  hemorrhages 
from  the  mucous  membranes.  The  regular  eruption  appears 
somewhat  later,  but  does  not  run  a  perfectly  typical  course, 
being  represented  in  some  cases  only  by  a  few  vesicles.  In 
some  cases  death  results  in  a  few  hours,  before  any  eruption 
occurs,  the  patient  being  overwhelmed  by  the  virulence  of 
the  disease.  In  other  cases  death  does  not  occur  until  from 
the  third  to  the  seventh  day. 

5.  Vanoloid. — This  disease  is  small-pox  occurring  in  a 
modified  form  in  a  person  who  is  but  partially  protected 
by  vaccination  or  by  a  previous  attack.  According  to 
the  extent  of  the  protection,  varioloid  occurs  in  all  grades 
of  severity,  so  that  the  severer  grades  merge  into  true, 
unmodified  variola,  while  in  the  lesser  grades  the  patient 
may  not  seem  to  be  sick  at  all.  No  matter  how  trifling 
the  attack  may  be,  it  is  true  variola,  and  is  capable  of 
causing  the  disease  in  others  in  even  the  most  malignant 
forms. 

Generally  varioloid  runs  a  milder  course  and  one  of  shorter 
duration  than  small-pox.  The  stage  of  invasion  lasts  for 
two  or  three  days.  There  may  be  a  chill,  with  moderate 
fever,  headache,  pains  in  the  back  and  bones,  and  vomiting, 
while  in  very  light  cases  these  symptoms  may  not  be  severe 


SMALL- POX.  57 

enough  to  prevent  the  patient  from  bein^^  at  work  and  out 
of  doors. 

The  eruption  is  that  of  variola,  but  it  is  less  abundant, 
the  pustules  do  not  reach  the  same  size  nor  penetrate  so 
deeply,  and  the  areola  of  inflamed  skin  is  frequently  absent. 
Many  of  the  vesicles  dry  up  and  are  not  converted  into  pus- 
tules. With  the  appearance  of  the  eruption  the  fever  falls 
to  normal  and  the  other  symptoms  of  the  invasion  disap- 
pear and  frequently  do  not  return.  In  more  severe  cases 
the  symptoms  of  the  secondary  fever  are  slight  and  last  but 
a  day  or  so,  so  that  there  is  a  striking  lack  of  proportion 
between  the  appearance  of  the  patient  and  the  degree  of 
his  constitutional  symptoms.  Desiccation  begins  from  the 
fifth  to  the  seventh  day,  and  the  resulting  cicatrices  are 
small  or  are  absent. 

Complications  and  Sequelae  of  small-pox  are  numerous, 
and  are  due  not  only  to  the  severe  infectious  nature  of  the 
disease,  but  also  to  the  suppurative  foci.  There  may  be 
laryngitis,  oedema  of  the  glottis,  or  necrosis  of  the  carti- 
lages, resulting  in  stenosis,  necessitating  intubation  or 
tracheotomy. 

Broncho-pneumonia  is  a  common  complication,  especially 
in  the  severer  cases.  There  may  be  pleurisy.  Nephritis  is 
rare,  although  the  urine  usually  contains  a  small  amount  of 
albumin.  There  may  be  orchitis.  During  the  suppurative 
stage  there  may  be  developed  septicaemia  or  pyaemia  or 
arthritis.  In  rare  cases  a  disseminated  myelitis  has  been 
observed.  Convalescence  may  be  interrupted  by  boils,  by 
gangrene  of  the  skin,  or  by  erysipelas.  Ulceration  of  the 
cornea  is  but  rarely  seen.  During  convalescence  there 
may  be  a  post-febrile  insanity  or  paralyses  from  peripheral 
neuritis. 

Prognosis. — The  prognosis  depends  upon  the  degree  of 
protection  afforded  the  patient  by  vaccination.  Varioloid 
is  very  seldom  fatal  in  those  protected  by  vaccination,  while 
in  those  totally  unprotected  the  mortality  ranges  from  30  to 
40  per  cent.  The  prognosis  depends  also  upon  the  severity 
of  the  attack,  the  hemorrhagic  and  malignant  forms  being 
almost    certainly    fatal,    the    confluent    form    being    very 


58  MAXi'AL    OF   THE   PRACTICE    OF  MEDICI.XE. 

dangerous,  while  the  discrete  form  affords  a  large  percent- 
age of  recoveries.  It  depends  also  upon  the  age  and  the 
condition  of  the  patient,  being  most  fatal  in  children  and 
old  people,  in  the  debilitated,  and  in  drunkards.  The 
prognosis  is  affected  also  by  the  presence  of  compli- 
cations. 

Treatment. — If  vaccination  and  revaccination  could  be 
performed  thoroughly,  variola  would  become  extinct.  After 
exposure  to  variola,  revaccination  should  be  resorted  to,  and 
it  is  probable  that  vaccination  even  in  the  earliest  stages  of 
the  disease  itself,  if  done  before  the  fourth  day,  greatly  mod- 
ifies its  severity. 

Patients  with  variola  should  properly  be  treated  in  con- 
tagious hospitals,  as  few  private  houses  afford  sufficient 
means  for  thorough  isolation  and  disinfection.  When  this 
cannot  be  done,  quarantine  should  be  conducted  on  the 
•strictest  principles,  and  should  be  continued  until  the  skin 
and  the  hair  are  absolutely  free  from  crusts  and  scales.  All 
articles  that  come  in  contact  with  the  patient  should  be 
sterilized  or  be  destroyed. 

The  room  should  be  kept  moderately  cool  and  well  ven- 
tilated. Patients  are  rendered  worse  by  being  kept  too  hot. 
The  occurrence  of  mania  should  be  anticipated  by  careful 
watching  and  by  having  the  windows  barred.  The  diet 
should  be  of  milk. 

The  fever  is  best  treated  on  hydropathic  principles  ;  the 
headache  and  backache  are  to  be  combated  by  opium  or 
phenacetine.  Sleep  may  be  procured  by  sulphonal,  chloral- 
amide,  or  codeia. 

The  patient  should,  if  possible,  be  prevented  from  scratch- 
ing. Great  care  should  be  exercised  in  the  strictest  cleans- 
ing of  the  eyes  and  in  preventing  them  from  being  infected 
by  their  being  rubbed  with  pus-stained  hands.  P'or  the 
cleansing  a  saturated  solution  of  boric  acid  is  to  be  pre- 
ferred. 

As  the  extent  of  the  pitting  depends  entirely  upon  the 
depth  of  the  pustules,  there  is  no  method  of  treatment 
known  by  which  pitting  can  be  prevented.  It  seems,  how- 
ever, that  the  intensity  of  the  pustules  is  modified  by  ex- 


VACCINATION.  59 

eluding  the  light  and  by  keeping  them  covered  with  strips 
of  gauze  constantly  wet  with  weak  solutions  of  bichloride 
or  of  carbolic  acid.  This  application  also  relieves  the  pain 
and  itching.  Isolated  pustules  may  be  painted  twice  a  day 
with  lo  per  cent,  carbolic  acid  in  alcohol.  When  crusts 
form  they  are  to  be  softened  by  applications  of  lard  or  of 
vaseline  to  prevent  them  from  floating  in  the  air  and  thus 
carrying  the  infection.  The  other  symptoms  and  compli- 
cations should  be  treated  on  general  principles. 

VACCINIA;  VACCINATION. 

Vaccination  was  first  performed  in  1798  by  Jenner,  and 
its  value  is  now  universally  acknowledged.  The  vaccine 
may  be  procured  by  means  of  the  scabs  of  patients  vacci- 
nated (humanized  virus),  or  be  taken  direct  from  the  calf 
(bovine  virus).  If  the  humanized  virus  be  used,  it  is  of  the 
utmost  importance  that  it  be  taken  from  a  healthy  subject 
free  from  every  trace  of  syphilitic  and  tubercular  taint.  As 
a  rule,  bovine  virus  obtained  fresh  from  reliable  sources 
should  be  used. 

In  a  primary  vaccination  there  appears  in  from  twenty- 
four  to  thirty-six  hours  a  papule  which  on  the  fifth  or  sixth 
day  becomes  an  umbilicated  vesicle  surrounded  by  an  indu- 
rated inflammatory  zone.  This  papule  on  the  eighth  or 
ninth  day  changes  to  a  pustule,  which  dries  up,  and  the 
brownish  scab  resulting  falls  off  on  the  twentieth  to  the 
twenty-fifth  day,  leaving  the  characteristic  scar.  In  patients 
who  have  already  been  vaccinated  successfully  there  may 
be  either  no  result,  or  an  irregular  atypical  vesicle,  or  a  local 
ulceration  on  an  inflammatory  base. 

About  the  third  day  of  vaccination  there  begins  a  moder- 
ate fever,  often  preceded  by  chilly  feelings,  with  malaise, 
restlessness,  and  irritability,  these  symptoms  being  espe- 
cially marked  in  children.  These  symptoms  increase  mod- 
erately until  pustulation  is  completed ;  then  they  subside. 
The  neighboring  lymphatic  glands  become  swollen,  painful, 
and  tender. 

The  protection  afforded  varies  with  the  completeness  of 
the  vaccination  and  with  the  time  that  has  elapsed  since  it 


6o  M.-lXr.lL    OF   THE   PRACTICE    OF  MEDICIXE. 

was  last  performed.  Every  bab\-  sliould  be  wiccinated, 
preferably  between  the  second  and  third  months,  and 
thereafter  every  seven  years — oftener,  however,  if  exposed 
to  small-pox  or  during  an  epidemic.  Should,  under  these 
latter  circumstances,  a  revaccination  be  unsuccessful,  it 
should  be  repeated. 

Complications  of  vaccination  are  due  either  to  lack  of 
cleanliness  or  to  impure  virus  employed,  and  should  not 
occur  if  proper  precautions  be  taken.  There  may  be  slough- 
ing ulcers,  gangrene  of  the  skin,  or  erysipelas.  Septicaemia 
may  develop  in  neglected  cases.  Impetigo  contagiosa  has 
been  known  to  result.  The  patient  may  be  inoculated 
with  syphilis  from  humanized  virus  taken  from  diseased 
patients,  the  double  infection  resulting  in  the  primary  lesion 
at  the  site  of  inoculation.  There  ma}-  be  observed  vesicles 
about  the  inoculation,  or  a  general  eruption  of  vesicles  from 
absorption  of  the  virus. 

VARICELLA. 

Definition  and  Synonym. — Varicella  is  a  contagious  dis- 
ease especially  of  childhood,  and  is  characterized  by  a  vesic- 
ular eruption.     Synonym:  Chicken-pox. 

Etiology, — Varicella  occurs  in  sporadic,  endemic,  and  epi- 
demic forms.  It  is  contagious  throughout  its  course,  but 
the  contagious  principle  is  of  a  low  grade  of  intensitx'.  It  is 
almost  exclusively  a  disease  of  children,  but  it  ma}'  occur 
in  young  adults.  One  attack  does  not  afford  absolute  im- 
munity from  subsequent  attacks. 

The  exact  virus  has  not  been  determined  definitely. 
There  is  no  connection,  immediate  or  remote,  between  this 
disease  and  variola  or  varioloid. 

Symptoms. — The  period  of  incubation  is  from  eight  to 
seventeen  days,  and  it  is  unattended  by  symptoms.  The 
invasion  is  marked  by  chilly  feelings  in  some  patients  and  by 
feverishness,  the  temperature  rarely  being  higher  than  102° 
F.  except  in  very  young  children,  in  whom  a  fever  of  104° 
F.  is  not  unusual  Convulsions  are  rare  at  the  onset.  There 
is  apt  to  be  vomiting,  and  the  child  complains  of  lassitude 
and  of  pains  in  the  back  and  legs.     These  symptoms  last 


SCARLET  FEVER.  6 1 

for  but  a  few  days.  In  some  cases  the  constitutional  symp- 
toms are  so  slight  that  except  for  the  eruption  the  child  may 
seem  well. 

The  eruption  appears  in  about  twenty-four  hours,  first 
on  the  chest  and  back  or  on  the  foreliead  and  face,  and  con- 
sists of  small  raised  spots  which  in  a  few  hours  become 
vesicles.  These  vesicles  vary  greatly  in  size,  the  larger  ones 
usually  appearing  on  the  forehead  ;  they  are  rarely  umbili- 
cated ;  they  collapse,  as  a  rule,  by  a  single  puncture  ;  they  ap- 
pear superficial,  and  not  deeply  seated  ;  and  they  are  but 
rarely  surrounded  by  an  inflammatory  halo.  A  few  vesicles 
become  pustular,  but  the  majority  in  a  day  or  so  simply  shrivel 
up,  leaving  crusts  which  fall  off,  usually  leaving  no  cicatrices, 
although  circular  scars  may  result  from  the  larger  and 
deeper  vesicles.  Fresh  crops  of  eruption  appear  during  the 
first  two  or  three  days,  so  that  the  eruption  can  be  seen  in 
all  stages  of  development.  The  eruption  also  appears  in 
any  of  the  mucous  membranes ;  the  vesicles,  becoming 
macerated,  leave  superficial  ulcers. 

In  a  few  cases  there  appears  a  scarlatinal  rash  before  the 
regular  eruption.  In  rare  cases,  in  debilitated  children, 
there  may  be  gangrene  of  the  skin,  or  hemorrhages  into  the 
eruption  and  skin  and  from  mucous  membranes. 

The  prog-nosis  is  regularly  good  except  for  the  severer 
forms  in  very  puny,  weakly  children. 

Treatment. — The  patient  should  be  kept  in  bed  during 
the  febrile  stage,  and  in  the  house  until  the  skin  is  free  and 
clear.  A  child  should  be  isolated  from  other  children,  but 
may  associate  with  adults. 

SCARLET    FEVER. 

Definition  and  Synonym. — Scarlet  fever  is  an  acute  in- 
fectious, contagious  disease  with  an  eruption,  fever,  and 
pharyngitis,  and  with  a  tendency  to  cause  an  inflammation 
of  the  kidneys.     Synonym :  Scarlatina. 

Etiology. — The  disease  is  contagious  from  the  invasion 
until  the  end  of  desquamation.  The  poison  is  conveyed  b}' 
the  exhalations  of  the  patient,  by  personal  contact,  or  through 
the  medium  of  a  third  person,  and  is  spread  by  the  scales  of 


62  MAXL'AL    OF   THE    PRACTICE    OF  MEDICLXE. 

the  desquamation;  these  scales,  which  float  in  the  air  and  are 
deposited  in  clothing,  bedding,  and  rooms,  may  remain  in  the 
hair  long  after  convalescence.  The  poison  possesses  extra- 
ordinary vitality,  so  that  contaminated  fomites  may  convey 
the  contagion  even  after  months  or  years.  The  poison 
may  be  carried  great  distances  and  ma\'  be  convcjed  also 
in  milk.  The  exact  nature  of  the  poison  has  not  definitely 
been  determined. 

The  disease  occurs  both  in  isolated  cases,  due  always  to 
contagion  of  some  previous  case,  and  in  epidemics,  which 
vary  greatly  in  their  virulence.  It  is  most  common  in  the 
fall  and  winter  months. 

Susceptibility  to  the  disease  varies,  some  people  being 
exempt.  This  exemption  may  run  in  families.  The 
disease  usually  attacks  children,  50  per  cent,  of  all  cases 
occurring  before  the  fifth  year,  90  per  cent,  before  the  tenth 
year.  Young  infants  are  rarely  attacked.  Adults  become 
less  and  less  susceptible  with  advancing  years.  One  attack, 
with  but  the  rarest  exception,  procures  future  immunity. 

The  disease  is  said  to  occur  with  special  frequency  in 
puerperal  women  and  after  surgical  operations,  but  it  is 
now  supposed  that  these  cases  are  really  septicaemia  with  a 
septic  erythema,  which  often  desquamates,  as  docs  any  long- 
continued  hyperaemia  of  the  skin. 

The  relation  between  scarlet  fever  and  diphtheria  is  at 
present  unsettled.  A  patient  may  have  the  two  diseases 
together  from  a  mixed  infection,  or  a  scarlatina  may  occur 
with  membrane  in  the  throat,  or  a  diphtheria  may  occur 
with  a  septic  erythema.  Careful  bacterial  investigations  are 
required  to  settle  the  relationship  of  the  two  diseases. 

Pathology. — The  characteristic  lesions  consist  in  the 
eruption  and  the  pharyngitis.  No  traces  of  the  eruption 
are  observed  after  death,  except  in  the  hemorrhagic  form. 
The  pharynx  usually  presents  the  appearance  of  a  catarrhal 
inflammation. 

The  complicating  inflammations  are  exceedingly  numer- 
ous and  important.  There  may  be  follicular  tonsillitis  or 
pseudo-membranous  inflammation  of  the  tonsils,  pharynx, 
or  larynx.     There  may  be  cellulitis  of  the  neck  that  may 


SCARLET  FEVER.  63 

go  on  to  gangrene  or  suppuration,  the  pus  containing  strep- 
tococci. There  may  be  infection  of  the  middle  ear  with 
otitis  media,  perforation,  and   deafness. 

Respiratory  complications  are  not  common,  although 
broncho-pneumonia  may  occur.  In  rare  cases  there  may 
be  pericarditis  or  endocarditis,  and  less  frequently  menin- 
gitis. The  spleen  is  usually  found  enlarged  during  the 
height  of  the  disease. 

In  nearly  all  cases  there  is  found  a  parenchymatous 
degeneration  of  the  kidney,  but  there  may  be  either  acute 
exudative  or  acute  diffuse  nephritis.  These  renal  changes 
are  the  most  important  and  formidable  of  all  the  complica- 
tions of  the  disease,  constituting  the  so-called  "  scarlatinal 
nephritis." 

Symptoms. — Incubation. — This  period  is  pretty  con- 
stantly seven  days,  although  its  extreme  limits  are  between 
twenty-four  hours  and  two  weeks.  During  this  period 
there  are  no  symptoms. 

Invasio7i. — The  invasion  is  sudden  and  striking,  being 
marked  by  fever,  sore  throat,  and  vomiting.  This  trinity 
of  symptoms  occurring  suddenly  should  always  excite  the 
suspicion  of  scarlatina.  There  may  be  initial  chilly  feelings, 
or  convulsions  in  young  children.  An  actual  chill  is  rare. 
The  vomiting,  which  is  usually  severe  and  apparently 
uncalled  for,  may  be  projectile.  The  fever  mounts  rapidly, 
and  reaches  103°  to  105°  F.  within  a  few  hours,  few  diseases 
showing  such  a  rapid  rise.  There  is  pain  on  swallowing; 
the  throat  is  dryish ;  the  glands  at  the  angle  of  the  jaw  are 
swollen  and  tender.  On  inspection  there  may  be  only  the 
appearance  of  a  catarrhal  pharyngitis  either  mild  or  severe, 
or  there  may  be  added  a  follicular  tonsillitis.  The  pulse 
becomes  rapid  and  is  usually  of  high  tension.  The  face  is 
flushed,  and  the  child  at  once  looks  seriously  ill.  There  may 
be  repeated  convulsions  or  talkative  delirium,  according  to 
the  severity  of  the  disease  and  the  nervous  constitution  of 
the  patient.  There  is  usually  some  nocturnal  wandering  of 
the  mind.  In  rare  cases  either  the  vomiting,  the  fever,  or 
the  sore  throat  may  be  absent. 

Eruption. — The  eruption  appears  on  the  evening  of  the  first 


64  MAXL'AL    OF  THE   rRACTICE    OF  MEDICIXE. 

Of  on  the  second  da)-,  twelve  or  twenty  four  hours  after  the 
onset,  although  it  may  be  delayed  until  forty-eii^ht  hours  ;  it 
consists  of  minute  red  points,  not  elevated  above  the  level 
of  the  skin,  appearing  first  on  the  throat,  breast,  and  back, 
and  rapidly  spreading  ov^er  the  entire  body,  imparting  to  it 
the  color  of  a  boiled  lobster.  The  chin  and  the  mouth  are 
usuall}'  left  clear,  giving  a  highly  characteristic  appearance 
and  making  diagnosis  easy  between  this  disease  and  measles 
or  small-pox.  The  face,  moreover,  is  not  usually  so  much 
involved  as  in  measles.  By  stroking  the  rash  white  lines 
stand  out  with  characteristic  vividness.  The  eruption  may 
cover  the  entire  body,  or  it  may  appear  in  patches  sepa- 
rated by  areas  of  normal  skin,  giving  a  peculiar  mottled 
appearance,  or  in  rare  cases  the  eruption  may  appear  only 
on  the  face,  the  bod}-,  or  the  extremities. 

There  is  usually  considerable  itching,  especially  during 
the  intensity  of  the  eruption.  When  the  eruption  is  well 
marked  the  skin  is  often  diffusely  swollen  and  inflamed,  pro- 
ducing an  uncomfortable  feeling  of  tension.  The  rash  lasts 
for  two  or  three  days  and  then  gradually  fades. 

While  the  eruption  is  developing  the  pharyngeal  symp- 
toms continue.  After  the  initial  vomiting  of  the  onset  there 
are  rarely  gastro-intestinal  symptoms.  The  tongue  presents 
the  so-called  "  strawberry  "  appearance,  the  papillae  in  the 
tip  and  edges  standing  out  like  shining  red  pearls  above  the 
epithelial  coating.  The  fever  remains  high  during  the 
development  of  the  eruption,  frequently  reaching  as  high  as 
105°  or  106°  F.,  and  then  gradually  subsides  with  the  fading 
of  the  eruption,  becoming  normal  about  the  seventh  day, 
although  there  is  frequently  a  slight  afternoon  rise  through- 
out the  entire  period  of  desquamation.  At  the  height  of  the 
fever  there  are  apt  to  be  nervous  symptoms — restlessness, 
nocturnal  wanderings,  or  even  delirium  with  convulsions — 
but  with  its  subsidence  these  symptoms  rapidly  improve, 
the  pharnygitis  disappears,  and  convalescence  begins. 

Desquamation. — Desquamation  begins,  after  the  fading 
of  the  eruption,  in  large  flakes.  This  desquamation  is  espe- 
cially noticeable  about  the  hands  and  feet,  epidermal  casts 
of  the  fingers  and  toes  being  frequently  thrown  off  entire. 


SCARLET  FEVER.  65 

These  flakes  are  potent  factors  in  the  spread  of  the  disease, 
and  the  patient  should  not  return  to  ordinary  hfe  until 
desquamation  is  completed.  Usually  desquamation  lasts 
into  the  third  or  fourth  week,  but  it  may  last  much  longer. 
It  is  exceedingly  rare  for  it  to  be  absent  altogether. 

Variations  from  the  regular  course  of  scarlatina  are  fre- 
quently observed,  and  are  due  in  most  part  to  varying  inten- 
sity of  infection.  Of  these  variations,  mention  will  be  made 
only  of  the  most  common. 

I.  Mild  and  Rudimentary  Cases. — The  invasion  is  marked 
only  by  a  slight  transitory  fever  and  moderate  angina.  The 
eruption  may  be  scanty,  extending  over  a  small  portion 
of  the  body  only,  disappearing  in  from  a  few  hours  to  a 
day,  or  it  may  be  absent  altogether.  There  is  usually,  fol- 
lowing the  eruption,  a  slight  though  evident  desquama- 
tion lasting  into  the  second  or  third  week.  These  cases 
are  frequently  spoken  of  as  "  sympathetic  sore  throats," 
and  are  usually  seen  in  partially  unsusceptible  adults 
who  have  been  exposed  to  scarlatina.  They  are  really 
true  cases  of  mild  scarlatina,  and  are  not  only  capable 
of  spreading  the  disease,  but  may  also  be  followed  by  com- 
plications, especially  nephritis.  To  such  a  rudimentary 
scarlatina  many  a  supposedly  primary  nephritis  owes  its 
origin. 

2.  Severe  and  Prolonged  Cases. — The  onset  is  usually  severe, 
the  temperature  rising  to  106°  or  107°  F.  and  the  prostra- 
tion and  cerebral  symptoms  being  pronounced.  The  erup- 
tion in  these  cases  may  be  scanty.  The  fever  and  the  con- 
stitutional symptoms  usually  continue  into  the  second  week. 
These  are  bad  cases,  but  they  are  not  to  be  considered  as 
hopeless. 

3.  Malignant  Cases. — The  invasion  is  marked  by  a  rapid 
rise  of  temperature,  frequently  as  high  as  106°  or  108°  F., 
with  cerebral  symptoms  of  ominous  gravity — restlessness, 
delirium,  convulsions,  passing  into  coma.  There  is  urgent 
dyspnoea ;  the  pulse  becomes  increasingly  rapid  and  feeble. 
In  these  cases  the  patient  is  overwhelmed  by  the  virulence 
of  the  poison,  and  dies  in  coma  or  collapse  in  from  eighteen 
to  thirty-six  hours.    As  a  rule,  there  is  no  eruption,  although 

5 


66  MANUAL    OF   THE   PRACTICE    OF  MED/CEVE. 

a  scanty  at\'pical  rash   nia\'  appear  should  the  patient  hve 
to  the  second  or  third  da\'. 

4.  Hemorrhagic  Cases. — These  are  severe  cases  with  a 
disposition  to  bleed  from  the  mucous  membranes  and  into 
the  skin,  the  latter  hemorrhages  appearing  as  petechias  and 
large  ecchymoses.  Cerebral  s\'mptoms  are  apt  to  be  pro- 
nounced. There  are  usually  vomiting  and  diarrhoea,  and 
frequently  dyspnoea.  The  temperature  may  not  be  high. 
The  prognosis  is  bad,  the  patient  usually  dying  in  two  or 
three  days. 

5.  Angina  Cases. — This  type  of  scarlet  fever  is  character- 
ized by  the  predominance  of  throat  symptoms  and  compli- 
cating inflammations.  The  pharynx  and  fauces  are  usually 
intensely  inflamed  and  their  tissues  much  swollen,  making 
speech  and  swallowing  painful  and  difficult.  There  is  fre- 
quently a  membranous  exudate  which  may  spread  from 
the  pharj'nx  and  tonsils  to  involve  the  naso-pharynx  and 
nose,  or  downward  to  the  larynx,  where  the  membrane  may 
cause  obstruction  to  the  breathing  and  asphyxia.  There 
may  be  necrosis  of  the  throat-tissues  that  may  lead  to  large 
sloughs,  and  if  large  arteries  are  involved  fatal  hemorrhage 
may  result.  The  glands  of  the  neck  become  enlarged,  and 
frequently  proceed  to  abscesses  and  cellulitis.  Otitis  media 
is  apt  to  result  by  infection  through  the  Eustachian  canals. 
The  patient  rapidly  passes  into  profound  sepsis  with  its 
attendant  symptoms — a  condition  which  is  rarely  recovered 
from. 

Complications. —  i.  Sufficient  mention  has  already  been 
made  of  the  important  throat  and  car  complications  and  of 
the  glandular  swelling  and  suppurations. 

2.  The  complicating  lesions  of  the  kidneys  are  exceedingly 
common.  Very  few  cases  of  scarlatina  run  their  course 
without  the  kidneys  being  involved  in  one  of  three  ways : 
(i)  by  acute  degeneration  ;  (2)  by  acute  exudative  nephritis  ; 
(3)  by  acute  diffuse  nephritis.  These  varieties  of  nephritis 
have  been  admirably  differentiated  by  Delafield,  and  his 
classification  will  be  followed. 

{a)  Acute  degeneration  of  the  kidney,  or  parenchymatous 
nephritis,  belongs  to  the  first  and  second  weeks  of  the  dis- 


SCARLET  FEVER.  6/ 

ease,  and  is  not  different  from  the  degeneration  occurring  in 
the  course  of  any  severe  infectious  disease.  The  urine  may 
be  diminished  sHghtly  in  quantity,  and  it  usually  contains 
albumin  and  casts  in  moderate  amounts.  The  course  is 
mild,  unattended  by  constitutional  symptoms,  and  ends  in 
recovery. 

{b)  Acute  exudative  nepliritis  belongs  to  the  second  and 
third  weeks,  following  either  a  mild  or  a  severe  attack  of  scar- 
latina. In  severe  cases  the  urine  is  scanty  or  suppressed  ; 
its  gravity  usually  is  unchanged  ;  albumin  and  casts  are 
abundant;  there  maybe  blood.  There  are  uraemic  symp- 
toms— headache,  nausea  and  vomiting,  dyspnoea,  convulsive 
twitchings.  In  some  cases  there  is  added  contraction  of 
the  arteries  with  high-tension  pulse  and  disturbed  heart- 
action.  The  patient  becomes  anaemic  and  the  face  puffy, 
the  oedema  frequently  becoming  general  with  fluid  in  the 
serous  cavities.  The  temperature  is  raised,  and  it  remains 
remittingly  high  during  the  acute  stage  of  the  nephritis. 
In  mild  cases  there  may  be  only  moderate  changes  in 
the  urine ;  ursemic  symptoms  may  be  unobserved.  The 
fever  is  slight  or  absent.  Between  these  two  there  are  all 
grades  of  severity.  These  cases  run  about  four  weeks  and 
usually  terminate  in  recovery,  a  small  proportion  only  being 
fatal. 

{f)  Acute  diffuse  nephritis  occurs  in  the  third  week  and 
during  convalescence.  It  is  really  a  post-scarlatinal  nephri- 
tis, and  may  develop  after  either  mild  or  severe  cases.  It 
runs  an  acute  or  a  subacute  course.  The  acute  cases  begin 
suddenly  and  resemble  a  severe  attack  of  exudative  nephritis. 
The  subacute  cases  develop  gradually.  There  is  apt  to  be 
repeated  vomiting,  which  is  always  to  be  regarded  with  sus- 
picion in  a  patient  convalescing  from  scarlatina.  Anaemia 
and  dropsy  progress  slowly.  The  urine  is  regularly  dimin- 
ished in  quantity,  and  it  contains  abundant  albumin  and 
casts.  In  some  cases  the  primar}^  changes  are  the  first 
symptom.  In  all  cases  of  diffuse  nephritis  the  disease  is  apt 
to  continue  with  more  or  less  rapidity,  with  or  without  re- 
mission, until  the  death  of  the  patient.  In  rarer  cases  the 
lesion  becomes  chronic. 


68  MAXi'AL    OF   THE   PRACTICE    OF  MEDICINE. 

3.  I)ifiaininatu)n  of  sinnis  uicmbrancs,  meningitis,  may 
occur  Endocarditis  and  pericarditis  are  more  frequent. 
The  so-called  "  scarlatinal  rheumatism  "  occurs  usually  as 
the  eruption  is  fading,  and  involves  especially  the  hands  and 
feet,  although  the  large  joints  may  be  affected  as  well.  The 
joints  are  painful,  and  may  be  swollen  and  inflamed.  The 
process  is  septic,  and  not  rheumatic,  in  its  nature.  Recovery 
is  effected  in  a  few  weeks,  though  suppuration  or  permanent 
deformity  may  result. 

4.  Liflaimnatioii  of  the  vnisclcs,  myositis,  may  occur,  espe- 
cially in  the  neck-muscles,  with  pain,  tenderness,  and  con- 
traction. The  muscles  may  in  rare  cases  remain  perma- 
nently contracted. 

The  prognosis  is  influenced  by  the  character  of  the  epi- 
demic (5  to  30  per  cent,  mortality),  the  age  and  general  con- 
dition of  the  child,  the  severity  of  the  attack,  and  the  nature 
of  the  complications.  A  guarded  prognosis  must  always  be 
given,  as  dangerous  complications,  especially  nephritis,  may 
occur  even  during  convalescence. 

Treatment. — The  patient  should  be  isolated  strictly  until 
the  completion  of  desquamation.  The  room  should  be  well 
ventilated,  free  from  draughts,  and  should  have  a  tempera-' 
ture  of  about  70°  F.  The  patient  should  be  kept  in  bed 
until  the  temperature  has  been  normal  for  a  week,  after 
which  time  the  child  may  be  allowed  about  the  room.  The 
diet  should  be  of  milk  during  the  febrile  period  ;  broths, 
eggs,  fruit,  and  light  cereals  may  be  allowed  during  early 
convalescence ;  but  no  animal  food  should  be  taken  until 
the  fourth  week.  The  best  preventive  of  nephritis  is  a  rigor- 
ous milk  diet. 

There  is  no  specific  medication.  Symptoms  must  be 
treated  on  general  principles. 

Fever. — At  the  onset  aconite  may  be  given  in  drop  doses 
every  quarter  of  an  hour  until  arterial  tension  is  decreased, 
and  then  every  two  or  three  hours  to  hold  the  pulse  at  that 
point.  Should  the  fever  be  high,  it  is  best  treated  by  hydro- 
therapy, which  has  the  additional  advantage  of  calming 
the  nervous  symptoms.  For  this  purpose  baths,  the  cold 
pack,  sponging  with  water,  or  the  ice-cap  may  be  employed 


SCARLET  FKl'ER.  69 

without  the  least  danger.  The  "  driving  in  "  of  the  erup- 
tion, with  disastrous  consequences,  is  mythical.  Internal 
antipyretics  should  not,  as  a  rule,  be  employed. 

The  nervous  symptoms  may  be  controlled  by  hydro- 
therapy, by  phenacetine  (gr.  ij-v)  to  a  child  five  years  of 
age,  or  by  chloral.  The  following  prescription  has  been 
proven  useful : 

T^.  Chloral  hydrate,  gr.  ij ; 

Camphor-water,  TTLxv ; 

Syrup  of  orange-peel,    ad  .5j. — M. 
Sig.  Dose  for  a  child  four  years  old,  repeated  every  three 
or  four  hours. 

Or,  I^.  Chloral  hydrate,  gr.  ij ; 

Peppermint-water,  §ss. — M. 

Sig.  Dose  for  a  child  four  years  old,  every  three  or  four 
hours. 

This  prescription  is  also  valuable  to  correct  the  initial 
vomiting. 

The  pharyngitis  should  always  be  treated.  Gargles  do 
not  prove  of  much  use  in  children,  and  rarely  in  adults.  Po- 
tassium chlorate  is  to  be  avoided  because  of  its  toxic  effects 
on  the  kidneys.  The  pain  is  best  relieved  by  cloths  wrung 
out  of  hot  water,  applied  frequently  to  the  neck  and  covered 
by  oil  silk.  In  some  cases  cold  applications  to  the  throat 
are  more  grateful.  The  mouth  and  throat  must  be  kept  clean 
to  avoid  the  spread  of  the  infection,  they  being  frequently 
rinsed  out  with  a  saturated  solution  of  boric  acid,  and 
sprayed  every  two  to  four  hours  with  a  solution  of  bichlo- 
ride of  mercury  (i  :  5000)  or  with  peroxide  of  hydrogen 
(3  per  cent,  solution). 

The  daily  anointing  of  the  skin  with  a  bland  antiseptic 
ointment  relieves  the  itching  and  the  feeling  of  tension  and 
prevents  the  dissemination  of  the  scales.  Lard,  cacao  butter, 
or  olive  oil  may  be  used,  to  each  ounce  of  which  carbolic 
acid  (gr.  xx),  thymol  (gr.  x),  or  menthol  (gr.  x)  may  be  . 
added.  Previous  to  the  inunction  the  skin  should  be  cleansed 
daily  with  soap  and  warm  water. 

The  temperature  should  be  taken  at  times  during  con- 


/O  MA.yr.lL    OF   THE   PRACTICE    OE  MEDICINE. 

valescencc.  The  heart,  lungs,  and  urine  should  be  exam- 
ined every  few  days,  even  if  the  progress  of  the  case  seems 
satisfactory. 

Nephritis  is  to  be  treated  as  though  it  were  a  primary 
disease. 

The  septic  inflammation  of  the  joints  is  best  treated  by 
hot  applications  and  by  saline  laxatives.  Ichthyol  ointment 
(oSs  to  oj)  niay  be  serviceable.  Salicylic  acid  and  its  deriva- 
tives occasionally  seem  to  do  good,  but  they  are  uncertain. 

Cervical  adenitis  and  cellulitis  are  to  be  treated  on  gen- 
eral rules. 

Before  the  patient  returns  to  ordinary  life  desquamation 
must  be  over  entirely.  Several  warm  cleansing  baths  with 
repeated  shampooing  are  to  be  employed  to  remove  all 
scales  from  the  skin  and  the  hair. 

MEASLES. 

Definition  and  Synonym. — Measles  is  an  acute  conta- 
gious disease  characterized  by  an  initial  coryza  and  a  maculo- 
papular  eruption.     Synonym  :   Rubeola. 

Etiology. — The  disease  is  endemic,  and  from  time  to  time 
assumes  epidemic  proportions.  It  most  frequently  attacks 
children,  especially  those  under  eight  years  of  age,  but  un- 
protected adults  are  more  liable  to  the  infection  than  to 
scarlet  fever,  the  infection  being  more  intense  and  suscepti- 
bility to  it  being  much  more  universal.  It  is  contagious 
throughout  its  course,  especially  during  the  eruption,  and 
there  are  grounds  for  believing  it  contagious  even  during 
the  period  of  incubation.  The  poison  is  conveyed  by  the 
breath,  by  the  secretions,  especially  of  the  nose,  and  by 
the  branny  desquamation.  It  may  be  carried  by  the  air,  by 
fomites,  or  by  a  third  person.  One  attack  does  not  always 
procure  immunity,  but  there  may  be  a  second,  a  third,  or 
even  a  fourth  attack,  although  recurrences  are  not  so  com- 
mon as  supposed. 

The  exact  contagion  has  not  been  determined,  but  it  is 
known  to  possess  less  vitality  and  a  shorter  duration  of  life 
than  the  poison  of  scarlet  fever.  Under  ordinary  circum- 
stances it  is  usually  a  mild  disease,  but  epidemics  in  crowded 


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MEASLES.  71 

tenement- houses  and  in  armies  may  become  serious,  while 
epidemics  occurring  for  the  first  time  in  savage  tribes  may 
be  exceedingly  fatal,  the  mortality  being  even  25  per  cent, 
of  the  entire  population. 

Patholog-y. — The  eruption  and  the  catarrhal  inflammations 
of  the  conjunctivae  and  the  upper  respiratory  tract  constitute 
the  essential  lesions.  As  complicating  lesions  there  may 
be  found  broncho-pneumonia,  capillary  bronchitis,  swelling 
of  the  bronchial  glands,  and  less  frequently  pleurisy  or  lobar 
pneumonia.  There  may  be  hyperaemia  of  the  gastro-intes- 
tinal  mucosa  with  swelling  of  Peyer's  glands. 

Symptoms. — The  period  of  incubation  is  from  ten  to 
fourteen  days,  rarely  so  long  as  twenty  days.  During  this 
time  there  are  usually  no  symptoms,  although  in  some  cases 
the  child  may  be  feverish  and  irritable. 

Invasion. — The  child  becomes  listless  and  exhibits  the 
symptoms  of  a  feverish  cold.  There  are  usually  shivering 
attacks,  but  a  regular  chill  or  an  initial  convulsion  is  rare. 
There  are  redness  of  and  running  from  the  eyes,  with  pho- 
tophobia, sneezing,  snuffling,  and  running  from  the  nose, 
followed  by  cough  and  hoarseness.  Sore  throat  is  some- 
times complained  of,  but  is  not  so  common  nor  so  severe  as 
in  scarlet  fever.  Examination  may  show  hyperaemia  with 
small  red  spots  on  the  hard  and  the  soft  palate.  Koplik's 
spots  consist  of  small  bluish-white  points  surrounded  by  a 
red  areola,  and  are  seen  on  the  buccal  surfaces  and  sides  of 
the  tongue  in  the  pre-eruptive  stage.  They  are  best  ob- 
served by  everting  the  cheek  in  the  presence  of  strong  sun- 
light. It  is  claimed  that  they  occur  in  every  case  of  measles, 
that  by  them  a  diagnosis  can  be  made  before  the  eruption 
appears,  and  that  they  are  not  present  in  other  exanthemata. 
The  temperature  rapidly  rises  to  102°  or  104°  F.,  remitting 
somewhat  on  the  second  and  third  days,  becoming  again 
elevated  upon  the  appearance  of  the  eruption.  There  may  be 
nausea  or  vomiting  and  nervous  symptoms  depending  on  the 
severity  of  the  attack  and  the  constitution  of  the  child.  In 
some  cases  these  symptoms  are  slight,  the  child  not  feeling 
well,  having  apparently  a  trifling  cold  with  but  moderate 


72  M.IXi'AL    OF   THE   PR.IC77CF.    OF  MEDICINE. 

feverishness.  The  stage  of  iinasion  lasts  for  three  or  four 
days, 

TJic  Stage  of  Enipiion. — The  eruption  usually  appears  on 
the  fourth  day,  being  seen  first  on  the  face  and  neck,  and 
then  rapidly  spreading  over  the  chest  and  body.  It  consists 
of  small  round  spots,  slightly  elevated,  so  that  they  may 
impart  a  shotty  feeling  to  the  finger ;  these  spots  increase 
in  size  and  assume  a  roundish  or  crescentic  outline.  The 
rash  is  hypersemic,  disappearing  on  pressure,  although  in 
some  cases  there  may  be  petechi^e.  The  rapiditj'  of  develop- 
ment varies,  the  eruption  becoming  characteristic  in  some 
cases  in  a  few  hours,  in  other  cases  not  for  several  days. 
The  eruption  closely  resembles  that  of  poisoning  by  shell- 
fish or  that  produced  by  antipyrine.  The  eruption  is  fully 
developed  by  the  end  of  two  or  three  days,  and  then  begins 
to  fade,  being  followed  by  a  fine  branny  desquamation.  At 
the  height  of  the  eruption  there  may  be  some  swelling  and 
inflammation  of  the  intervening  skin,  but  usually  it  is  nor- 
mal in  appearance. 

When  the  eruption  appears  the  temperature  again  rises, 
reaching  its  maximum  at  the  time  of  the  greatest  development 
of  the  eruption,  after  which,  usually  in  the  second  day  of  the 
eruption,  the  temperature  begins  to  fall,  frequently  by  crisis. 
Restlessness,  sleeplessness,  or  even  general  convulsions  and 
delirium,  may  accompany  the  exacerbation  of  the  fever. 
The  catarrhal  symptoms  attain  their  maximum  while  the 
eruption  is  developing,  and  then  gradually  subside. 

Variations  in  its  Course. —  i.  In  rare  cases  there  may  be 
no  catarrhal  symptoms  during  the  period  of  invasion. 

2.  There  are  very  light  cases  in  which  there  may  be  no 
eruption.  After  the  regular  period  of  incubation  the  patient 
becomes  indisposed,  feverish,  and  has  a  coryza — as  it  is  said, 
"  sickens  for  the  disease,"  but  the  eruption  is  not  developed. 

3.  In  some  cases  the  eruption  appears  as  early  as  thirty- 
six  hours,  or  it  may  be  deferred  until  the  sixth  day. 

4.  There  are  cases  of  marked  severity  characterized  by 
high  fever  (105°  or  106°  F.)  and  cerebral  symptoms,  con- 
vulsions, delirium,  and  stupor. 

5.  In  some  epidemics,  especially  in  armies  and  in  savage 
tribes  where  measles  appears  for  the  first    time,   may   ap- 


MEASLES.  73 

pear  malignant  cases,  the  so-called  "  hemorrhagic "  or 
"  black  "  measles.  The  invasion  is  sudden  and  intense ; 
prostration  is  extreme;  there  arc  convulsions  or  delirium 
or  even  coma.  The  eruption  becomes  hemorrhagic  ;  hem- 
orrhages occur  in  the  skin  and  from  mucous  membranes, 
These  cases  are  almost  always  fatal. 

Complications  and  Sequelae. — The  most  important  are 
those  of  the  respiratory  system.  A  mild  form  of  bronchitis 
is  common  to  the  disease,  but  in  debilitated  subjects,  in 
asylum  children,  and  in  severe  forms  of  the  disease  the  in- 
flammation is  apt  to  extend  and  to  lead  to  broncho-pneu- 
monia. This  complication  runs  a  regular  course,  and  is  the 
cause  of  death  in  the  vast  majority  of  fatal  eases.  There  may 
be  a  swelling  of  the  bronchial  glands  that  render  them  liable 
to  tubercular  infections,  which  may  be  the  origin  of  acute 
miliary  tuberculosis.  Thus  in  asylums  fatal  cases  of  tuber- 
culosis frequently  follow  epidemics  of  measles  after  a  little 
interval.  In  some  cases  there  may  be  a  tubercular  bron- 
cho-pneumonia at  the  start  from  added  tubercular  infec- 
tion. Lobar  pneumonia  and  pleurisy  may  less  commonly 
occur.  There  may  be  protracted  and  severe  conjunctivitis. 
Croupous  laryngitis  may  occur.  There  may  be  otitis 
media. 

In  weakly  children  there  occurs  rarely  gangrene  of  the 
cheeks  or  of  the  vulva  (cancrum  oris  or  noma).  In  some 
cases  there  is  exhausting  diarrhoea,  which  may  assume  a 
dysenteric  character  with  bloody,  slimy  passages.  True 
nephritis  is  rare,  although  albuminuria  is  common  in  the 
height  of  the  disease.  The  disease  may  be  complicated  by 
whooping-cough. 

Prognosis. — The  prognosis  is  generally  good  except 
when  severe  epidemics  occur  in  tenements,  armies,  and 
among  savage  races  in  virgin  soil.  Death  seldom  occurs 
from  the  disease  itself,  but  from  pulmonary  complications. 
The  prognosis  is  not  good  in  children  under  the  age  of  two 
years.  The  possibility  of  subsequent  tuberculosis  must  be 
considered. 

Treatment. — The  patient  should  be  isolated  until  desqua- 
mation is  completed.  Especial  care  should  be  exercised  to 
to  prevent  delicate  children  with  weak  lungs  or  a  tubercu- 


74  M.lXr.AL    OF   THE   PRACTICE    OF  MEDICIXE. 

lar  predjsposition  from  being  exposed  to  the  disease.  The 
room  should  be  of  an  even  temperature  (about  70°  F.)  and 
well  ventilated.  There  is  no  advantage  in  keeping  the  room 
too  hot.  The  patient  should  remain  in  bed  until  three  or 
four  days  after  the  fever  has  gone,  and  during  the  febrile 
period  should  be  kept  on  a  milk  diet.  Water  may  be  given 
freely.  The  majority  of  uncomplicated  cases  need  no  further 
treatment,  though  special  symptoms  may  be  treated  as  they 
arise. 

The  fever  rarely  needs  treatment.  Should  it  be  high 
(over  104°  F.),  it  may  be  reduced  by  sponging  with  water. 
Cool  baths  may  be  employed  with  benefit. 

Conjunctivitis  is  best  treated  by  careful  cleansing  of  the 
eyes  with  a  saturated  boric-acid  solution ;  or  a  few  drops 
of  a  solution  of  atropia  (gr.  j  :  Sj)  or  of  alumnol  (gr.  v :  oj) 
may  be  employed.  For  the  redness  of  the  eyelids  the  un- 
guentum  hydrargyri  oxidi  flavi  (U.  S.  P.)  may  be  used.  In 
severe  cases  the  room  may  be  darkened  slightly  by  blinds 
or  by  screens  to  relieve  the  photophobia. 

Restlessness,  delirium,  and  sleeplessness  are  best  con- 
trolled by  sodium  bromide  or  phenacetine. 

The  cough,  if  troublesome,  is  best  treated  by  paregoric 
and  syrup  of  ipecac  in  small  doses. 

The  itching  of  the  skin  may  be  relieved  by  washing  with 
a  solution  of  bicarbonate  of  soda  or  by  oiling  the  skin  with 
lard  or  with  cacao  butter. 

Other  symptoms  as  they  arise  are  to  be  treated  on 
general  principles.  During  desquamation  the  skin  should 
be  oiled  daily  to  prevent  dissemination  of  the  branny 
scales. 

During  convalescence  great  care  should  be  taken  to  build 
the  child  up  and  to  avoid  most  especially  the  least  possi- 
bility of  tubercular  infection.  Too  much  care  cannot  be 
taken  in  this  reeard. 


RUBELLA. 

Etiology  and  Synonyms. — Rubella  is  rather  rare,  occur- 
ring chiefly  as   epidemics,  which   are   frequently  extensive. 


RUBELLA.  75 

Sporadic  and  endemic  cases  are  exceedingly  infrequent.  It 
is  a  disease  entirely  distinct  from  measles,  although  closely 
resembling  it  in  many  of  its  clinical  features.  It  is  conta- 
gious to  both  adults  and  children,  and  one  attack  procures 
future  immunity.  Synonyms:  German  measles;  Roseola; 
Rotheln. 

Symptoms. — Incubatioji. — The  period  of  incubation  is 
usually  two  weeks. 

Invasion. — The  symptoms  of  the  invasion  resemble  those 
of  measles,  but  are  much  milder  and  are  of  shorter  duration. 
There  is  a  slight  fever,  rarely  over  ioo°  F.,  with  headache, 
nausea  and  vomiting, 'coryza,  sore  throat,  and  swelling  of 
the  glands  at  the  back  of  the  neck  that  is  almost  charac- 
teristic. These  symptoms  rarely  continue  longer  than 
twenty-four  hours.  In  many  cases  they  are  so  slight  as 
to  be  unnoticed. 

The  eruption,  which  appears  in  from  twenty-four  to  forty- 
eight  hours,  is  first  seen  on  the  face  and  chest,  thence  spread- 
ing generally.  It  consists  of  small  round,  raised  spots,  of  a 
pinkish  rose-color,  which  are  usually  discrete  and  which 
frequently  are  seen  on  the  palate.  They  are  rarely  crescentic. 
They  may  become  confluent,  the  consequent  reddening 
of  the  skin  closely  resembling  the  scarlatina  rash  ;  but  the 
eruption  is  more  erythematous,  is  not  punctiform,  and  in 
places  shows  a  papular  character.  In  a  certain  number  of 
cases  there  are  developed  from  the  papules  a  few  vesicles 
which  may  become  pustules.  This  is  never  the  case  with 
scarlatina  nor  with  measles. 

The  eruption  lasts  for  two  or  three  days  and  then  fades. 
There  may  be  a  slight  branny  desquamation. 

During  the  eruption  there  may  be  some  feverishness,  an 
aggravation  of  the  pharyngitis,  and  swelling  of  the  glands  at 
the  back  of  the  neck.  In  many  cases,  however,  the  only 
.symptom  is  the  eruption. 

The  prognosis  is  perfectly  good. 

Treatment. — Few  diseases  need  so  little  treatment  as 
rubella.  The  case  should  be  isolated  to  avoid  the  spread 
of  the  disease. 


y^  MAXi'AL    OF   THE   PRACTICE    OF  MEDICIXE. 

EPIDEMIC    PAROTITIS. 

Definition  and  Synonym. — Epidemic  parotitis  is  an 
acute  contagious  disease  characterized  b}-  inllaniniation  of 
the  saHvary  glands.     Sj'iiofijnn :  Mumps. 

Etiology. — Parotitis  occurs  both  as  an  endemic  and 
an  epidemic  disease,  epidemics  being  usually  extensive. 
It  is  a  disease  of  childhood  and  adolescence,  attacking  in- 
fants and  elderly  people  but  rarely.  It  is  more  frequent 
among  males  than  among  females.  It  is  personally  con- 
tagious from  the  last  few  da}'s  of  the  period  of  incubation 
until  the  subsidence  of  the  symptoms.  The  exact  poison 
has  not  been  absolutel}''  proven,  although  a  bacillus  paro- 
tidis  has  been  described. 

Lesion. — The  lesion  consists  in  the  swelling  and  conges- 
tion of  one  or  of  both  parotid  glands,  and  occasionally  of 
the  submaxillary  glands  as  well. 

Symptoms. — The  period  of  incubation  is  between  two 
and  three  weeks  and  is  unattended  by  symptoms.  The 
disease  begins  with  fever — usually  not  over  ioi°  F., 
but  it  may  be  as  high  as  103°  or  104°  F. — and  at- 
tendant febrile  symptoms,  nausea,  restlessness,  and  pros- 
tration. The  local  symptoms  become  noticeable  in  from 
twenty-four  to  thirty-six  hours,  although  in  some  cases 
they  may  precede  the  fever.  The  patient  complains  of  a 
feeling  of  tension,  more  rarely  of  actual  pain  with  tender- 
ness, referred  to  the  parotid  gland  of  one  side.  The  gland 
is  swollen,  giving  the  patient  a  characteristically  comical 
appearance.  Deglutition  and  speaking  aggravate  the  pain. 
There  may  be  pharyngitis  or  earache. 

The  inflammation  reaches  its  height  in  from  three  to  six 
days  and  then  subsides.  It  is  usual  for  the  inflammation 
to  start  on  one  side,  the  other  parotid  gland  becoming 
affected  in  a  day  or  so.  More  rarely  both  glands  may  be 
affected  simultaneously,  or  the  inflammation  may  be  sub- 
siding on  the  side  first  affected  before  the  involvement  of 
the  other  side,  so  that  the  duration  of  the  disease  is  doubled. 
The  lesion  is  rarel)'  unilateral  throughout. 

In  some  cases  the  submaxillary  glands  may  secondarily  be 


EPIDEMIC   PAR  OTITIS.  yy 

involved.  With  the  subsidence  of  the  inflammation  the  fever 
and  the  constitutional  symptoms  disappear. 

While  the  course  is  generally  mild,  there  are  cases  which 
run  a  severe  course,  with  high  fever,  rapid  and  feeble  heart- 
action,  and  delirium. 

Orchitis  occurs  more  frequently  in  some  epidemics  than 
in  others.  It  is  rarely  seen  before  puberty,  and  double 
orchitis  is  infrequent.  The  orchitis  gives  rise  to  pain  and 
tenderness ;  the  testicle  is  hard  and  swollen  ;  there  may  be 
fluid  in  the  tunica  vaginalis. 

The  temperature  rises,  frequently  to  103°  or  104°  F.,  and 
remains  high  until  the  orchitis  begins  to  subside,  which  is 
usually  in  from  five  to  ten  days.  Subsequent  involvement 
of  the  other  testicle  may  prolong  the  disease  for  another 
week.  In  females  there  may  be  vulvo-vaginitis,  or  the 
breasts  may  be  enlarged  and  tender.  Inflammation  of  the 
ovaries  is  rare. 

Complications  and  Sequelae. — There  may  be  meningitis, 
mania,  or  post-febrile  insanity.  There  may  be  suppuration 
or  gangrene  of  the  parotid  glands.  Severe  orchitis  may  be 
followed  by  atrophy.  In  some  cases  arthritis  has  been  ob- 
served. There  may  be  deafness,  which  frequently  is  per- 
manent. 

Treatment. — The  patient  should  be  isolated  until  the  dis- 
appearance of  acute  symptoms,  and  during  the  febrile  period 
should  be  kept  in  bed  and  on  a  light  diet.  The  parotiditis 
is  best  treated  locally  by  applications  of  cold ;  should,  how- 
ever, heat  be  more  grateful,  poultices,  applications  of  hot 
cloths,  or  dry  cotton  covered  with  oiled  silk  may  be  em- 
ployed. Resolution  may  be  hastened  by  applications  of 
ichthyol  ointment  (3ss  :  sj)  or  of  iodine  ointment. 

Orchitis  is  to  be  treated  by  rest  in  bed,  elevation  of  the 
testicle,  and  applications  of  cold.  In  the  latter  stages  ich- 
thyol ointment  or  unguentum  plumbi  iodidi  may  be  em- 
ployed with  benefit.  Other  symptoms  should  be  treated  on 
general  principles. 


78  MJXi'AL    OF  THE   PRACTICE    OF  MEDICLXE. 

WHOOPING-COUGH. 

Definition  and  Synonym. — Whooping-cough  is  an  acute 
contagious  disease  with  inflammation  of  the  respiratory  tract, 
a  paroxysmal  cough,  and  a  characteristic  "  whoop."  Syu- 
oiiyui :    Pertussis. 

Etiolog-y. — Whooping-cough  occurs  in  endemic  and  epi- 
demic cases,  the  epidemics  being  most  frequent  in  the  winter 
and  early  spring  months,  and  often  being  associated  with 
epidemics  of  measles.  The  disease  is  personally  contagious, 
though  concentrated  and  prolonged  exposure  is  usually 
required.  One  attack  procures  immunity.  The  actual 
cause  is  probably  due  to  a  short  bacillus  growing  in  cultures 
with  well-marked  characteristics,  first  described  in  1887  by 
Afanassjew.  The  majority  of  cases  occur  in  children  under 
six  years  of  age,  though  no  age  is  exempt.  In  negroes  it 
runs  a  more  severe  course. 

Lesion. — The  lesion  consists  in  a  catarrhal  inflammation 
of  the  nose,  lar)-nx,  trachea,  and  bronchi.  As  complicating 
lesions  there  ma\-  be  found  extensive  bronchitis  of  the  smaller 
tubes,  broncho-pneumonia,  inflammation  of  the  bronchial 
glands,  and  emphysema  of  the  vesicular  or  interlobular 
variety. 

Symptoms. — The  inaibation  period  of  the  disease  is  about 
two  weeks,  although  this  is  difficult  to  determine  owing  to 
the  insidious  onset.  The  symptoms  begin  with  bronchitis 
and  coryza  similar  to  those  of  an  ordinary  severe  cold;  these 
symptoms  continue  without  improvement  for  from  one  to 
three  weeks.  Then  appear  the  characteristic  coughing 
attacks  from  which  the  disease  is  named.  The  attack  be- 
gins with  a  series  (fifteen  to  twenty)  of  coughs  so  rapid  and 
spasmodic  that  the  child  cannot  breathe.  Suffocation  seems 
imminent;  the  face  is  suffused;  the  eyes  run;  the  tongue 
is  cyanotic  and  protruding.  The  child  is  terrified  and  sits 
up  in  bed  or  runs  to  the  nurse  or  the  mother.  After  this 
series  of  coughs  there  is  a  long,  deep  inspiration  with  the 
sound  of  the  characteristic  whoop,  immediately  after  which 
the  convulsive  coughs  may  be  repeated.  In  some  cases  the 
whoop  is  the  first  indication  of  a  coughing  attack.     In  rare 


WHOOPING-COUGH.  79 

cases  there  is  only  the  paroxysmal  cough  without  any 
whoop.  The  attack  is  often  followed  by  the  raising  of  a 
little  tenacious  mucus,  which  gives  relief 

Very  severe  attacks  may  be  accompanied  by  vomiting  or 
regurgitation  of  food,  by  relaxation  of  the  sphincters,  by 
convulsions,  or  by  hemorrhages  from  the  nose,  mouth, 
stomach,  or  under  the  conjunctiva.  In  rare  cases  there 
may  be  symptoms  of  cerebral  or  subdural  hemorrhage. 
The  number  of  separate  attacks  varies  from  three  to  eighty 
during  the  twenty-four  hours.  The  attacks  are  frequently 
induced  by  emotions,  by  crying,  by  attempts  at  swallowing, 
by  close,  dusty  air,  and  by  changes  in  temperature,  and  they 
are  usually  more  frequent  at  night  than  during  the  day-time. 

The  general  health  suffers.  Severe  cases  are  accompanied 
by  fever  and  prostration.  The  vomiting  and  the  induce- 
ment of  an  attack  by  swallowing  interfere  with  proper  nutri- 
tion, while  the  child  is  nervous  and  fretful  from  loss  of 
sleep.  There  is  usually  found  superficial  ulceration  on  each 
side  of  the  frenum  of  the  tongue,  and  between  the  attacks 
the  face  is  frequently  swollen,  the  lower  lids  are  puffy,  and 
the  tongue  is  enlarged  and  of  a  bluish  color. 

After  the  paroxysmal  stage  has  lasted  for  from  three  to 
six  weeks  the  attacks  become  less  severe,  the  whoop  ceases, 
and  there  remains  only  a  terminal  bronchitis  which  slowly 
declines.  The  whole  duration  of  the  disease  is  in  this  w^ay 
protracted  for  from  six  to  twelve  weeks.  In  adults  the 
disease  runs  a  more  severe  and  energetic  course,  with 
marked   depreciation  in  general  health. 

Complications  and  Sequelae. — The  pulmonary  complica- 
tions have  been  mentioned  under  the  heading  of  Lesions. 
Their  association  with  whooping-cough  renders  the  prog- 
nosis much  worse  than  if  they  occurred  primarily. 

Paralysis  from  cerebral  or  intradural  hemorrhage  is  a  rare 
sequela. 

Whooping-cough  is  frequently  followed  by  acute  tuber- 
culosis or  by  tubercular  broncho-pneumonia,  from  an  added 
infection  of  the  inflamed  lung  or  the  bronchial  glands.  Qui- 
escent tubercular  deposits  may  also  be  called  into  activity. 

In  some  cases  there  will  be  a  return  of  the  Avhoop  at  inter- 


80  MAXr.lI.    OF   THE   PRACTICE    OF  MEDICLXE. 

vals  for  months  whenever  bronchitis  is  contracted.  This  is 
not  a  recurrence,  but  is  merely  a  "  habit-spasm." 

Treatment. — Ex'cry  possible  care  should  be  emplo)'ed  to 
keep  children,  especially  if  delicate,  from  being  exposed. 
Negligence  in  this  regard  is  criminal.  The  contagion  is 
most  marked  during  the  paroxysmal  stage,  and  declines  with 
the  terminal  bronchitis,  but  does  not  persist  after  the  second 
month.  Isolation  and  quarantine  cannot  be  insi.sted  upon 
to  their  full  limits,  and  a  final  disinfection  of  the  rooms  and 
the  clothing  is  not  necessary,  as  the  contagion  is  conveyed 
by  the  breath  alone.  The  room  should  be  sunny  and  well 
ventilated.  In  mild  cases  without  pulmonary  complications 
the  child  can  go  out  in  favorable  weather.  The  proper 
feeding  of  the  child  is  important,  especially  if  there  be 
vomiting  during  the  attacks. 

Drug  treatment  is  largely  emplo)'ed,  and  many  alleged 
"  specifics  "  are  lauded  from  time  to  time.  No  one  form  of 
treatment  is  of  service  in  all  cases,  but  one  drug  after  another 
has  to  be  tried. 

During  the  catarrhal  stage  the  treatment  is  that  of  the 
bronchitis.  During  the  paroxysmal  stage  treatment  is 
directed  not  only  toward  the  bronchitis,  but  also  toward 
the  mitigation  of  the  paroxysms.  For  the  latter  purpose 
internal  sedatives  and  local  applications  are  employed. 

Internal  Sedatives. — The  doses  given  are  those  suitable 
for  a  child  two  years   old. 

Belladonna,  frequently  to  tolerance.  Initial  dose,  2  min- 
ims of  tincture  every  three  hours. 

Quinine,  in  full  doses,  gr.  j  every  two  hours. 

Chloral,  gr.  ij-iv  every  four  hours  :  efficient  in  many  cases, 
especially  to  secure  sleep  ;  may  advantageously  be  combined 
with  sodium  bromide  (gr.  iij-v),  especially  in  children  with 
convulsive  tendencies. 

Opium  or  codeia  is  to  be  used  only  in  the  severest  cases. 

Asafcetida  mixture  is  often  of  service  in  mild  cases. 

Antipyrine  (gr.  i-iij  every  two  or  three  hours)  is  often 
attended  by  most  brilliant  results. 

Phcnacctiiie  (gr.  ij-iij  every  three  hours)  has  been  found 
useful. 


EPIDEMIC  INELUENZA.  51 

Bromoform  (3  drops  in  simple  elixir  three  times  a  clay) 
acts  almost  as  a  specific  in  some  cases. 

The  disinfection  of  the  sleeping-room  with  sulphur,  the 
child  sleeping  there  in  clean  clothes  after  the  room  has  been 
aired,  often  cuts  short  the  paroxysmal  stage. 

Local  treatment  may  be  employed  if  not  resisted  by  the 
child — inhalation  of  the  vapor  of  carbolic  acid,  of  creosote, 
atomized  sprays  of  wine  of  ipecac,  i  per  cent,  solutions  of 
resorcin,  peroxide  of  hydrogen,  or  solutions  of  quinine. 

Insufflations  of  quinine,  i  per  cent,  solutions  of  resorcin, 
or  a  powder  of  salicylic  acid  gr.  x.  to  boric  acid  §ij,  may  be 
tried. 

In  many  cases,  during  the  decline  of  the  paroxysmal  stage 
a  change  of  climate  may  hasten  recovery.  In  severe  and 
protracted  cases  it  should  always  be  tried. 

EPIDEMIC    INFLUENZA. 

Definition  and  Ssnionym. — Epidemic  influenza  is  an 
acute  infectious  disease,  occurring  principally  in  pandemics, 
characterized  by  fever,  pains,  prostration,  and  by  inflamma- 
tion of  the  mucous  membranes.     Synonym  :  La  Grippe. 

Etiology. — The  disease  occurs  in  epidemics  which  spread 
over  whole  countries  or  quarters  of  the  globe  with  great 
rapidity,  attacking  large  numbers  of  people.  The  epidemics 
usually  start  in  the  East,  the  majority  arising  in  Russia. 
Until  1870,  ninety  such  epidemics  had  been  described.  The 
last  pandemic  occurred  in  1889-90.  The  disease  is  not 
affected  by  sex,  age,  condition  of  life,  climate,  or  atmospheric 
changes.  Sporadic  cases  occur  in  the  wake  of  the  epidemics. 
One  attack  does  not  procure  immunity.  The  disease  is 
probably  slightly  contagious  by  personal  contact,  and  possi- 
bly through  fomites,  but  in  the  large  epidemics  infection 
cannot  be  traced  with  any  certainty. 

The  actual  cause  of  the  disease  appears  to  be  a  bacillus 
first  described  in  1892  by  Pfeiffer.  This  is  a  short  bacillus 
with  bulbous  ends  that  is  found  in  the  sputum,  in  the 
tissue  of  the  lungs,  and  in  the  blood.  This  bacillus  is  never 
found  in  other  diseases,  is  constant  in  grippe,  and  it  causes 
the  disease  in  monkeys  and  apes  by  inoculation. 
6 


82  MAXr.lL    OF   THE   rRACTICE    OF  MEDICINE. 

Lesions. — The  regular  lesion  is  a  catarrhal  inllamniation 
of  the  respiratory  passages,  from  the  nose  to  the  bronchi  ; 
frequently  there  are  also  swelling  and  hypera^mia  of  the 
mucosa  of  the  stomach  and  intestines. 

Complicating  lesions  are  numerous.  The  most  import- 
ant are  those  of  the  respiratory  organs.  There  may  be  lobar 
pneumonia,  broncho-pneumonia,  pleurisy,  or  empyema. 
Less  frequently  are  noted  abscess  of  the  lung,  abscess  of 
the  brain,  meningitis,  purulent  pericarditis,  and  nephritis. 

Symptoms. — The  symptoms  arc  exceedingly  varied,  de- 
pending on  the  severity  of  the  infection,  the  reaction  on  the 
nervous  centres,  and  the  var\-ing  intensit}'  of  the  catarrhal 
inflammations  of  the  respiratory  and  gastro-intestinal  tracts. 
Complicating  lesions  also  add  their  symptoms. 

1.  Syniptonis  of  Infection. — The  onset  is  usually  abrupt, 
being  initiated  by  a  chill  or  by  chilly  feelings.  In  some 
cases  the  chill  is  absent.  Rarely  there  are  prodromata,  as 
evinced  by  lassitude  of  body  and  mind  for  several  days. 
The  temperature  rapidly  rises  to  ioi°  to  104°  F.  accord- 
ing to  the  severity  of  the  attack.  There  is  marked  prostra- 
tion from  the  first.  The  pulse  is  rapid  and  full.  It  may 
become  feeble  and  intermittent,  especially  in  the  old  and 
the  debilitated,  and  may  lead  to  heart  failure.  The  liver  and 
spleen  in  some  cases  are  enlarged. 

2.  Ncrvojis  Symptoms. — At  the  onset  there  is  severe, 
agonizing  headache,  usually  frontal,  less  frequently  general 
or  occipital.  This  headache  is  often  as  severe  as  in  men- 
ingitis, persisting  for  hours  or  days,  and  it  may  be  obsti- 
nately present  during  convalescence. 

Pain  and  tenderness  of  the  muscles  of  the  body,  especially 
of  the  legs  and  the  back,  are  constant  symptoms.  The 
patients  feel  bruised,  and  shift  their  position,  trying  to  find 
one  more  endurable. 

There  are  great  depression  of  spirits  and  an  inability  to 
concentrate  the  mind  which  may  last  long  into  convalescence. 
In  severe  cases  there  maybe  delirium  of  an  active  type  with 
hallucinations.     There  may  be  herpes  labialis  or  urticaria. 

3.  Catarrhal  Symptoms. — There  are  conjunctivitis,  redness 
and  oedema  of  the  lids,  and  increased  lacrymation.     Coryza 


EPIDEMIC  INEEUENZA.  83 

appears,  with  snuffling  and  sneezing.  Laryngitis  is  attended 
by  hoarseness,  pain,  and  a  severe  paroxysmal  cough  which 
often  continues  for  weeks  after  the  attack  without  being  im- 
proved materially  by  medication.  Pharyngitis  and  tonsil- 
litis are  usually  present.  The  bronchitis  may  be  mild  or 
severe,  and  is  marked  by  harassing  cough,  muco-purulent 
sputa,  which  may  contain  blood,  pain  in  the  chest,  and  the 
ordinary  physical  signs. 

4.  Gastro-i)itcstiiial  symptoms  consist  in  a  heavily-coated 
tongue,  persistent  vomiting,  diarrhoea,  tympanites,  and  pain 
and  tenderness  over  the  abdomen. 

Course  of  the  Disease. — The  relative  predominance  of 
the  above  .symptoms  varies  in  different  people  and  in  differ- 
ent epidemics.  In  all  cases  the  symptoms  of  general  infec- 
tion are  present,  but  the  nervous,  catarrhal,  or  gastro-intes- 
tinal  symptoms  vary  so  much  in  their  relative  intensity  as 
to  present  three  principal  types  of  the  disease — a  nervous 
form,  a  catarrhal  form,  and  a  gastro-intestinal  form.  No 
strict  line  of  demarcation  between  these  different  types  can 
be  made. 

Complications  and  Sequelae. — Pneumonia  is  by  far  the 
most  frequent  and  fatal  complication.  There  may  be  either 
broncho-pneumonia,  especially  in  children,  or  lobar  pneu- 
monia. The  latter,  which  involves  one  or  more  lobes,  with 
complete  or  incomplete  consolidation,  and  which  is  always 
associated  with  an  intense  general  bronchitis,  differs  from 
the  ordinary  course  of  lobar  pneumonia  in  the  following 
particulars  :  The  onset  may  not  be  so  abrupt,  being  insidious 
and  of  slow  development.  The  expectoration  is  that  of 
bronchitis,  rusty  sputum  being  usually  absent.  The  bron- 
chitis is  a  marked  feature,  adding  its  symptoms  and  physi- 
cal signs.  The  temperature  is  lower  than  that  of  a  primary 
pneumonia,  and  is  frequently  remittent.  Cyanosis  and  heart 
failure  are  more  frequent.  The  duration  is  longer  and  reso- 
lution is  more  tardy.  The  temperature  falls  gradually,  as  a 
rule,  and  not  by  crisis,  and  frequently  persists  after  resolu- 
tion. The  pneumonia  is  often  "  wandering,"  creeping  from 
place  to  place  until  a  considerable  part  of  the  lung  has 
become  involved.     Empyema,  pleurisy,  abscess  of  the  lung. 


84  MAXrAL    OF  THE   PRACTICE    OF  MEDICINE. 

mening^itis.  purulent  pericarditis,  and  acute  nephritis  may 
occur  during  or  after  the  attack,  and  give  their  regular 
symptoms. 

Convalescence  is  usually  slow  and  tedious,  and  is  at- 
tended often  by  weakness  of  body  and  of  mind.  There  may 
remain  obstinate  insomnia  or  cough.  Facial  neuralgia  or 
headache  may  persist,  and  in  some  cases  is  due  to  compli- 
cating empyema  of  the  antrum  of  Highmore.  There  may 
be  post-grippal  insanity  or  peripheral  neuritis.  Deafness 
may  result  from  otitis  media. 

During  and  after  epidemics  of  grippe  the  mortalit)'  from 
tuberculosis  is  manifesth-  increased,  quiescent  and  chronic 
tubercular  processes  being  stirred  into  activity. 

The  duration  of  an  uncomplicated  attack  varies  between 
three  and  seven  days.  It  may  be  protracted  by  reason  of 
the  complications.  Convalescence  may  be  either  rapid  or 
slow  and  tedious. 

Prognosis. — Grippe  itself  is  rarely  fatal  except  in  elderly 
or  debilitated  people  or  in  those  suffering  from  advanced 
pulmonary,  nephritic,  or  cardiac  disease.  In  these  cases 
the  disease  may  terminate  fatally  from  weakness  or  from 
cardiac  failure.  The  prognosis  is  largely  influenced  by  the 
nature  and  severity  of  the  complications. 

Treatment. — It  certainh'  seems  that  the  severity  of  the 
attack  can  be  modified  by  the  administration  of  large  doses 
of  quinine  at  the  onset.  At  least  gr.  xx-.xxx  should  be 
given  within  the  first  twenty-four  hours,  cinchonism  being 
controlled  by  phenacetine  or  by  sodium  bromide.  Aside 
from  this  the  treatment  is  entirely  symptomatic. 

The  headache  and  the  pains  in  the  bones  and  muscles  are 
best  relieved  by  repeated  small  doses  of  phenacetine,  prefer- 
ably combined  with  salol  (each  5  grains  every  two  hours), 
Antipyrine  and  antifebrine  are  to  be  avoided  if  possible,  be- 
cause of  their  depressing  effect.  Bromides  may  be  useful 
in  controlling  restlessness,  and  a  hot  bath  followed  by  a 
lO-grain  dose  of  Dover's  powder  is  often  of  great  comfort. 
Morphine  or  codeine  may  be  employed  in  severe  cases. 
If  headache  depends  upon  congestion  of  the  frontal  sinuses, 
inhalations  of  steam,  creosote,  or  menthol  are  of  service. 


DENGUE.  85 

The    following    prescription    is    most    satisfactory    for   the 
purpose  : 

Y^^.  Menthol,  gr.  x; 

Tinct.  benzoin,  comp.,     5j. — M. 
Sig.  A  teaspoonful  gradually  added  to  a  pitcherful  of  boil- 
ing water,  to  be  inhaled  three  times  a  day. 

Sleep  is  best  procured  by  sulphonal,  chloralamide,  or 
codeia. 

The  vomiting  is  to  be  treated  by  regulating  the  feedings, 
by  bismuth,  or  by  morphine. 

Diarrhoea  is  to  be  checked  by  opium  combined  with 
astringents. 

The  bronchitis  is  to  be  treated  after  the  ordinary  methods 
— by  sedatives,  by  expectorants,  and  by  counter-irritation 
applied  to  the  chest. 

Pneumonia  requires  its  appropriate  treatment,  especial 
care  being  taken  to  avert  heart  failure  by  the  timely  admin- 
istration of  stimulants  ;  alcohol,  digitalis,  and  strychnine  are 
most  usually  employed  for  this  purpose. 

The  depressing  and  enfeebling  influence  of  the  disease 
during  convalescence  requires  most  careful  attention.  The 
patient  should  not  return  too  soon  to  business ;  the  diet 
should  be  supporting ;  all  depressing  influences  should  be 
avoided ;  and  appropriate  tonics  should  be  administered. 
A  change  of  air  is  often  required.  This  supporting  treat- 
ment is  especially  indicated  in  those  who  present  evidences 
of  tubercular  disease. 

DENGUE. 

Definition  and  Synonyms. — Dengue  is  an  infectious  epi- 
demic disease  of  warm  latitudes,  characterized  by  febrile 
paroxysms,  pain  in  the  muscles  and  bones,  and  anomalous 
eruptions.     Sjnonyjns :  Dandy  fever ;  Breakbone  fever. 

Etiology. — The  disease  appears  in  extensive  epidemics 
confined  to  the  tropics  and  the  sub-tropics.  It  has  occurred 
in  the  Southern  United  States.  Large  numbers  of  people 
are  attacked,  susceptibility  being  almost  universal.  One 
attack  does  not  secure  immunity.     The  disease  is  supposed 


SG  MA.VrAL    OF   THE   PRACTICE    OF  MEDICINE. 

to  be  contagious  by  personal  contact  and  through  fomitcs. 
Epidemics  occur  in  the  summer  months,  and  are  checked 
by  colder  weather.  The  exact  poison  has  not  been  deter- 
mined. 

Patholog-y. — But  little  is  known  about  the  disease,  as 
fatal  cases  are  rare.     There  appear  to  be  no  essential  lesions. 

Sjanptoms. — The  period  of  incubation  is  about  four  days. 
The  onset  is  abrupt,  beginning  with  a  chill  or  chilly  feel- 
ings, or  with  convulsions  in  children.  The  temperature 
rapidly  rises  to  102°  to  106°  F.  according  to  the  severity 
of  the  attack,  and  is  accompanied  by  ordinary  febrile  .symp- 
toms. Cerebral  symptoms  are  frequent  in  the  cases  with 
high  temperature.  At  the  onset  are  developed  agonizing 
headache  and  backache.  The  muscles  are  sore  and  tender. 
The  joints  become  painful,  tender,  and  frequently  red  and 
swollen.  The  large  and  the  small  joints  are  equally  affected. 
Prostration  and  depression  are  marked.  In  some  cases  there 
may  appear  a  transitory  erythematous  rash.  In  rare  cases 
there  may  be  severe  vomiting  and  purging.  There  may  be 
hemorrhages  from  any  of  the  mucous  membranes  in  severe 
cases.  Lymphatic  enlargements  are  not  uncommon.  The 
febrile  paroxysm  lasts  from  three  to  five  days  and  terminates 
by  crisis,  the  fall  of  temperature  frequently  reaching  the  sub- 
normal, although  in  most  cases  a  moderate  fever  remains. 
At  the  crisis  there  may  be  sweating  or  diarrhoea.  As  the 
fever  falls  the  general  symptoms  disappear,  the  patient  feel- 
ing better,  though  often  prostrated  and  sore. 

The  period  of  remission  lasts  from  two  to  five  days,  and 
during  it  may  appear  a  variety  of  eruptions  which  are  not 
distinctive.  There  may  be  urticaria,  erythematous  eruptions 
of  all  kinds,  or  herpes.  The  severer  forms  may  be  followed 
by  desquamation. 

After  the  period  of  remission  there  occurs  a  second  par- 
oxysm of  fever  with  a  return  of  all  the  previous  symptoms. 
This  paroxysm,  however,  is  mild  and  lasts  only  for  two  or 
three  days,  terminating  again  by  crisis,  after  which  conva- 
lescence is  established. 

Convalescence  is  usually  slow  and  tedious  from  mental 
and  physical  incapacity. 


EPIDEMIC   CEREBRO-SPINyif.    MENfNGIT/S.  8/ 

The  prognosis  is  almost  uniformly  favorable. 
Treatment. — There    being    no    specific    treatment,    the 
symptoms  must  be  treated  on  general  principles. 

EPIDEMIC  CEREBRO-SPINAL    MENINGITIS. 

Definition  and  Synonym. — Epidemic  cerebro-spinal  men- 
ingitis is  an  acute  infectious  disease  characterized  by  inflam- 
mation of  the  cerebral  and  spinal  meninges.  Synonym: 
Cerebro-spinal  fever. 

Etiology. — This  disease,  which  has  been  recognized  only 
since  the  early  part  of  the  present  century,  occurs  chiefly 
in  epidemics,  although  sporadic  cases  are  frequently  seen. 
The  epidemics  are  most  frequent  and  severe  in  the  cold 
winter  months,  and  are  favored  by  poor  hygiene  and  by  the 
crowding  together  of  people,  as  in  garrisons  and  barracks. 
Children  are  more  susceptible  than  adults.  There  is  no 
evidence  that  the  disease  may  be  transmitted  by  food  or  by 
drinking-water.  The  disease  is  not  considered  contagious 
by  either  personal  contact  or  through  fomites,  although  rare 
cases  have  been  reported  which  render  it  imprudent  to  make 
too  dogmatic  an  assertion  in  this  regard. 

In  almost  all  the  recently-studied  cases  there  is  found  in 
the  exudate  a  lance-shaped  diplococcus  which  appears 
identical  with  the  diplococcus  of  pneumonia,  and  it  appears 
most  likely  that  this  is  the  specific  micro-organism  of  the 
disease.  It  is  frequently  found  associated  with  the  ordinary 
pus  organisms. 

Pathology. — The  brain  is  usually  congested.  The  veins 
and  sinuses  are  engorged  with  blood.  The  pia  mater  is  infil- 
trated with  an  exudate  of  fibrin,  serum,  and  pus  to  a  greater 
or  lesser  degree.  The  infiltration  may  be  confined  to  the 
base  or  it  may  be  more  generally  distributed.  It  is  more 
abundant  along  the  course  of  the  blood-vessels  and  in  the 
sulci.  The  lateral  ventricles  are  filled  \vith  serum,  which 
may  be  turbid  from  admixture  of  pus.  In  children,  as  a 
rule,  and  occasionally  in  adults,  this  fluid  may  distend  and 
dilate  the  ventricles,  and  in  chronic  cases  after  the  meningitis 
has  subsided  the  distention  of  the  ventricles  may  continue 
as  a  chronic  hydrocephalus. 


88  M.iXCAL    OF   THE   PRACTICE    OF  MEDICIiXE. 

The  pia  mater  covering  the  spinal  cord  shows  similar 
inflammatory  changes,  especially  on  the  posterior  aspect. 
The  brain-cortex  is  often  infiltrated  with  pus,  which  may 
form  small  abscesses.  The  cerebro-spinal  fluid,  which  is 
usually  increased,  may  be  turbid.  In  the  exudate  the  lance- 
shaped  cocci  are  found  frequently  with  ordinary  pus  cocci. 
The  lesions  may  involve  the  sheaths  of  the  cranial  nerves, 
leading  to  neuritis  and  perineuritis.  In  very  malignant 
cases  there  may  be  no  time  for  the  lesion  to  develop  before 
death. 

In  rare  cases  the  meningitis  is  of  the  cellular  variety.  The 
pia  may  appear  normal  or  lustreless  or  congested.  There 
is  neither  fibrin,  serum,  nor  pus,  but  there  is  a  marked  pro- 
liferation of  the  connective-tissue  cells  of  the  pia.  These 
cases  usually  run  a  different  clinical  course. 

The  remaining  lesions  are  not  distinctive,  being  those 
common  to  all  severe  infectious  diseases.  There  may  be 
hemorrhages  in  the  skin,  in  the  serous  membranes,  and  into 
the  viscera.  There  is  granular  and  fatty  degeneration  of  the 
liver-  and  kidney-cells  and  of  the  heart-muscle.  The  spleen 
is  usually  enlarged  and  soft. 

Symptoms. — The  period  of  incubation  is  usually  short, 
varying  from  a  few  hours  to  several  days.  During  this 
time  the  patients  may  complain  of  headache,  slight  feverish- 
ness,  and  lassitude. 

The  onset  is  usually  abrupt,  being  marked  by  a  chill, 
fever,  headache,  and  vomiting.  The  fever  may  reach  to 
I02°  or  104°  F.,  and  does  not  run  any  typical  course. 
While  high  fever  belongs  to  the  severe  cases,  the  reverse 
is  not  always  true.  In  some  cases  the  fever  may  not  be 
marked. 

The  headache  is  usually  frontal,  but  it  may  be  parietal, 
occipital,  or  general.  It  is  a  severe  headache,  persisting 
during  sleep  and  periods  of  stupor,  as  evinced  by  moaning, 
clasping  the  head  with  the  hands,  or  by  the  facial  aspects 
of  pain.  There  may  be  general  pains  in  the  bones  and 
muscles. 

The  vomiting  is   frequently  severe  and  distressing,  and 


EPIDEMIC  CEREBROSPINAL   MENINGITIS.  89 

does  not  depend  upon  the  giving  of  food  or  of  drink.  It 
may  assume  a  projectile  character. 

During  the  earher  stages  of  the  disease  there  are  nervous 
symptoms  of  irritation.  The  headache  has  already  been 
mentioned.  There  are  frequently  psychical  disturbances,  as 
shown  by  delirium,  which  may  be  maniacal.  Some  patients 
show  morbid  erotic  desires.  There  may  be  from  time  to 
time  a  sudden  sharp  cry,  the  so-called  "  hydrocephalic  cry." 
The  functions  of  the  cranial  nerves  are  exalted.  There  are 
photophobia,  usually  with  some  amount  of  conjunctivitis, 
intolerance  to  sounds,  facial  neuralgia,  and  muscular 
twitching. 

The  irritation  of  the  spinal  nerves  is  shown  by  pain,  ten- 
derness, and  contraction  of  the  muscles  of  the  back  of  the 
neck  that  may  amount  to  opisthotonos  if  the  muscles  of  the 
trunk  are  similarly  involved. 

The  skin  is  hypersesthetic,  the  least  touch  causing  exqui- 
site pain.  General  exaggerated  reflexes  are  highly  charac- 
teristic. There  are  twitchings  and  spasms,  and  frequently 
automatic  movements  of  the  muscles  of  the  arms  or  legs.. 
The  attitude  is  one  of  flexion.  Kernig's  sign  consists  in  the 
inability  to  extend  the  leg  on  the  thigh  when  the  thigh  is 
flexed  on  the  abdomen.  It  is  a  good,  but  not  an  invariable 
sign. 

The  pulse  is, at  first  increased  in  proportion  to  the  fever, 
becoming  slowed  and  full  when  the  brain  begins  to  be  com- 
pressed by  the  effusion  and  distention  of  the  ventricles.  It  is 
often  remarkably  variable  in  its  rapidity. 

Various  atypical  eruptions  may  be  seen  on  the  skin. 
Herpes  on  the  lips  or  the  face  occurs  in  half  the  cases.  As 
the  herpetic  vesicles  frequently  contain  the  characteristic 
micrococci  of  the  disease,  bacterial  examinations  ma}^  be 
serviceable  in  confirming  the  diagnosis.  There  may  be 
erythematous  blotches  or  urticaria  or  petechial  spots,  which 
may  be  so  grouped  as  to  suggest  a  nervous  origin. 

The  urine  usually  contains  small  amounts  of  albumin  and 
casts.  There  may  be  polyuria.  Glycosuria  has  been  observed 
in  a  certain  number  of  cases. 

Digestive  symptoms  are  not  pronounced, .with  the  excep- 


90       j/.i.vr.iL  OF  THE  practke  of  medicine. 

tion  of  tlie  initial  vomiting.  The  bowels  are  usually  obsti- 
nately constipated.  In  a  few  cases  a  coniplicatins;  dysentery 
has  been  observed.  The  abdominal  wall  may  be  markedly 
retracted,  presenting  a  "boat-shaped"  appearance.  There 
may  be  severe  abdominal  pain. 

///  tlic  latter  stages  of  the  disease  the  symptoms  of  nervous 
excitation  give  way  to  those  of  nervous  depression,  and 
symptoms  of  cerebral  compression  make  their  appearance. 
The  patient  usually  makes  no  more  actual  complaint  of 
headache,  although  it  is  evident  that  there  is  still  some 
pain  experienced.  There  are  increasing  dulness  and  apathy, 
which  may  proceed  to  stupor  and  coma.  There  may  be  pe- 
riods of  delirium,  usually  now  of  the  low,  muttering  variety. 
Photophobia  is  succeeded  by  lack  of  perception  of  light ; 
the  pupils  are  usually  dilated  and  do  not  react.  Noises  are 
not  objectionable.  The  muscular  twitchings  and  spasms 
give  way  to  weakness  and  paralysis,  which  are  most  marked 
in  the  face  and  in  the  eye-muscles,  producing  strabismus. 
The  temperature  continues  to  be  irregular.  The  respiration 
may  be  irregular,  or  even  of  the  "  Cheyne-Stokes"  variety. 
The  pulse  is  usually  slower  than  would  be  expected  from 
the  prostration  and  the  fever,  becoming  rapid  and  feeble, 
however,  toward  the  close  of  the  disease.  The  combination 
of  fever,  headache,  slow  pulse,  and  constipation  is  exceed- 
ingly characteristic  of  meningitis  in  any  of  its  forms.  At 
the  close  of  the  disease  there  may  be  diarrhoea  and  loss  of 
the  sphincter  control.  In  fatal  cases  there  may  be  ante- 
mortem  hyperpyrexia.  In  cases  that  recover  the  fever 
gradually  disappears,  while  other  symptoms  depart  more 
slowly. 

Lumbar  puncture  is  of  importance  in  the  differential  diag- 
nosis of  the  various  bacterial  forms  of  meningitis,  but  it  pos- 
sesses no  therapeutic  value.  The  puncture  should  be  made 
under  strict  antiseptic  precautions.  The  patient  lying  on  the 
right  side  with  the  knees  drawn  up,  the  needle,  preferably  an 
antitoxine  needle,  6  centimeters  long,  should  be  passed 
between  the  third  and  fourth  lumbar  vertebrae,  the  point 
being  entered  i  centimeter  to  the  right  of  the  median 
line,  and  directed  upward  and  slightly  inward.     Aspiration 


EPIDEMIC  CEREBRO-SPINAL   MENINGITIS.  9I 

is  not  necessary,  as  the  fluid  flows  easily  through  the  needle. 
No  ill  effects  are  to  be  expected.  There  should  be  made  a 
bacterial  examination  of  the  exudate  to  determine  what 
bacteria  are  present.  In  epidemic  cerebro-spinal  meningitis 
the  diplococci  can  be  demonstrated  in  two-thirds  of  the 
cases,  the  fluid  in  the  remaining  third  being  sterile. 

The  duration  of  ordinary  cases  is  between  one  and  three 
weeks,  although  more  protracted  cases  are  not  uncommon. 

Anomalous  cases  are  met  with,  especially  in  certain  epi- 
demics. 

1.  Course  in  Young  Babies. — Convulsions  are  frequent  at 
the  outset  and  throughout  the  disease ;  the  fever  is  high  ;  the 
pulse  is  rapid  throughout ;  the  child  passes  into  stupor  alter- 
nating with  restlessness,  and  death  in  coma  ensues. 

2.  Mild  Cases. — There  are  headache,  nausea,  vertigo,  and 
a  little  fever.  There  may  be  stiffness  of  the  neck  and  vom- 
iting. The  diagnosis  of  these  cases  is  difficult  except  dur- 
ing epidemics. 

3.  Intermittent  Cases. — The  regular  course  of  the  disease 
in  these  cases  is  marked  by  periods  of  improvement  and 
remission  of  fever  lasting  for  a  few  hours  or  days,  the  remis- 
sions recurring  at  regular  intervals.  The  case  may  be  mis- 
taken for  malaria  or  pyaemia. 

4.  Abortive  Cases. — Here  the  disease  begins  in  the  regular 
way,  but  recovery  is  rapid  after  a  few  days. 

5.  Malignant  Cases. — The  patient  is  suddenly  attacked 
by  a  chill,  headache,  and  high  fever.  The  pulse  is  feeble  and 
frequently  is  slow,  and  hemorrhagic  spots  usually  appear  on 
the  skin.  Cerebral  symptoms  develop  rapidly,  and  death 
from  toxsemia  occurs  in  a  few  hours  or  days,  before  lesions 
or  characteristic  symptoms  have  time  to  develop.  These 
cases  are  usually  seen  only  in  the  most  severe  epidemics. 

Complications. — There  may  be  bronchitis  or  broncho- 
pneumonia. Lobar  pneumonia  is  frequently  observed. 
There  may  be  pericarditis,  endocarditis,  or  pleurisy.  There 
is  usually  conjunctivitis,  but  more  serious  lesions  may  de- 
velop, such  as  purulent  keratitis  or  choroiditis  with  loss  of 
sight,  or  optic  neuritis  with  atrophy.  Arthritis  occurs  in 
some  epidemics,  the  joints  being  painful,  red,  and  swollen 


92  MAXCAL    OF  THE   PRACTICE    OE  MEDICIA'E. 

from  effusion  in  and  around  the  joint-cavities,  the  effusion 
in  some  cases  being  purulent. 

Sequelae. — Convalescence,  which  is  apt  to  be  slow  and 
tedious  from  prolonged  muscular  and  mental  weakness, 
may  be  complicated  by  relapses.  In  some  cases  the  lesion 
in  the  lateral  ventricles  continues  as  a  chronic  h\-droccphalus. 
The  patient  recovers  partially  from  the  acute  attack,  but  a 
little  fever  remains,  the  pulse  is  feeble,  and  there  is  great 
gastric  irritability.  The  pupils  are  usually  dilated.  Ema- 
ciation becomes  extreme.  The  patient  lies  in  apathy  or 
stupor  varied  by  periods  of  restlessness  and  moaning. 
These  cases  last  for  weeks,  and  final  recovery  is  rare. 

Some  patients  are  left  in  a  condition  of  bodily  and  mental 
weakness.  They  become  ansemic,  irritable,  forgetful,  and 
hysterical,  usually  recovering  after  a  lapse  of  months. 

There  may  be  paralysis  from  post-febrile  neuritis. 

There  may  be  sequelae  from  involvement  of  special  senses. 
There  may  be  partial  or  complete  blindness  from  corneal 
ulcerations,  from  choroiditis,  or  from  atrophy  of  the  optic 
nerve.  Permanent  deafness  may  result  from  perineuritis  of 
the  auditory  nerve  or  from  labyrinthine  disease,  many  cases 
of  deaf-mutism  being  due  to  this  disease. 

The  prognosis,  which  is  bad,  but  not  hopeless,  depends 
not  only  on  the  severity  of  the  symptoms,  especially  those 
of  cerebral  origin,  but  also  on  the  general  character  of  the 
epidemic,  the  mortality  ranging  from  20  to  75  per  cent,  in 
different  epidemics.  The  average  mortality  is  about  40  per 
cent.  Endemic  cases  are  usually  less  severe  than  those 
occurring  during   epidemics. 

Treatment. — The  treatment  is  entirely  symptomatic.  In 
robust  patients,  if  seen  early  at  the  outset,  local  bleeding  by 
leeches  applied  to  the  temples  or  behind  the  ears,  or  the 
application  of  wet  cups  to  the  nape  of  the  neck,  is  frequently 
of  much  benefit.  Relief  is  usually  afforded  by  the  contin- 
uous application  of  cold,  by  the  cold  coil,  or  by  ice-bags 
applied  to  the  head  or  the  spine.  Large  doses  of  ergot  are 
frequently  given  in  the  earlier  stages  to  diminish  cerebral 
congestion,  and  iodide  of  potassium  in  20-grain  doses  three 


D/rirrj/ERiA.  93 

times  a  day  is  warmly  recommended  throut^hout  for  its  sup- 
posed "  absorbent "  action. 

Blistering  is  now  considered  injudicious,  as  it  docs  no 
good  and  adds  to  the  discomfort  of  the  patient.  AppHca- 
tions  to  the  shaven  scalp  of  iodoform  ointment  and  mercu- 
rial inunctions  have  not  seemed  to  exert  a  favorable  effect. 

For  the  nervous  symptoms  sedatives  and  even  narcotics 
are  required.  Bromide  of  sodium,  hyoscyamine,  phenacetine, 
or  small  doses  of  atropine  may  be  enough  in  mild  cases,  but 
the  severer  forms  demand  morphine,  preferably  by  hypo- 
dermatic administration.  ■• 

High  temperatures  are  to  be  combated  by  hydrotherapy, 
and  every  indication  of  heart  weakness  must  be  met  by  the 
free  and  judicious  use  of  heart  stimulants. 

DIPHTHERIA. 

Definition. — Diphtheria  is  an  acute  contagious  disease 
due  to  infection  by  the  Klebs-Loeffler  bacillus,  and  charac- 
terized by  an  exudative  inflammation  of  mucous  membranes 
or  of  abraded  cutaneous  surfaces,  with  constitutional  symp- 
toms. 

Etiolog-y. — The  disease  is  endemic  in  all  large  cities,  and 
frequently  becomes  epidemic,  the  most  characteristic  epi- 
demics occurring  in  summer  hotels,  in  institutions,  and  in 
small  villages.  The  spread  of  the  disease  is  greatly  favored 
by  poor  hygiene,  bad  plumbing,  and  the  crowding  together 
of  people.  It  is  contagious  by  personal  contact,  and  may 
be  transmitted  by  clothing,  toys,  bedding,  etc.,  even  after  the 
lapse  of  months  or  of  years,  the  germ  having  intense  vital- 
ity and  duration  of  life.  Cases,  however,  in  which  the  con- 
tagious property  of  the  bacillus  has  been  retained  for  more 
than  one  year,  though  reported  in  medical  literature,  are  of 
questionable  authenticity. 

It  is  doubtful  whether  the  disease  is  communicable  by  the 
breath  alone.  It  is  known,  however,  that  the  greatest  con- 
tagion is  conveyed  by  the  secretions  and  by  loosened  bits 
of  membrane  from  the  infected  site  coughed  into  the  faces 
of  the  attendants  or  sucked  from  the  tracheotomy  wound 


94  M.lXr.lL    OF   THE   PRACTICE    OF  MEDICIXE. 

b\'  an  over-zealous  operator.  The  disease  nia\'  be  trans- 
mitted by  kissing.  Cases  are  reported  in  which  the  disease 
has  been  taken  from  diphtheritic  animals,  especially  cats. 

The  disease  is  usually  one  of  childhood,  one-half  the  cases 
occurring  before  the  fifth  >'ear,  although  it  is  common  enough 
in  those  under  fift}-.  It  may  occur  in  young  babies.  One 
attack  does  not  procure  immunity.  The  exciting  cause  is 
now  known  to  be  a  bacillus  desci'ibed  in  1883  by  Klebs  and 
in  1884  by  Loeffler,  and  bearing  their  combined  names.  Its 
length  is  a  trifle  less  than  the  tubercle  bacillus,  but  it  is 
broader,  with  clubbed  extremities.  It  is  readily  stained, 
shows  a  characteristic  growth  in  nutritive  media,  and  is 
capable  of  causing  the  disease  in  animals.  Cultures  are 
best  made  in  blood-serum,  colonies  in  agar-agar.  It  is 
destro}-ed  by  aqueous  solutions  of  bichloride  of  mercury 
(I  :  8000),  salicylic  acid  (i  :  2000),  and  carbolic  acid  (i  :  50). 
It  is  destroyed  also  by  boiling.  The  bacilli  are  usually 
found  only  in  the  pseudo-membrane,  though  exceptionally 
they  may  be  present  in  the  blood  and  in  the  viscera.  They 
may  persist  in  the  throat  for  so  long  as  three  weeks  after 
the  attack,  and  are  found  in  the  throats  of  25  per  cent,  of 
those  who  have  been  exposed  to  diphtheria.  They  are 
never  found  in  other  diseases. 

Infection  usually  occurs  through  slight  abrasions  of  the 
mucous  membranes,  and  is  favored  by  diseased  conditions 
of  the  upper  air-passages.  The  diphtheritic  ptomaine  has 
been  isolated,  and  its  injection  in  animals  has  been  followed 
by  all  the  symptoms  of  diphtheria  except  the  membrane. 

Immunity. — By  the  inoculation  of  attenuated  cultures  in 
some  animals  immunity  has  been  secured  ;  and,  what  is  more 
important,  infected  guinea-pigs  have  been  cured  by  inocu- 
lating them  with  the  blood  of  the  animals  rendered  thus 
immune.  At  the  present  time  diphtheria  in  the  human  sub- 
ject is  being  treated  by  this  method,  with  the  result  of 
reducing  the  mortality  one-half  If  these  inoculations  are 
begun  by  the  second  day  of  the  disease,  the  patient  almost 
invariably  recovers. 

Pathology. — The  essential  lesion  consists  of  a  croupous 
inflammation  of  mucous  membranes,  more  rarely  of  abraded 


jj/pirniER/A.  95 

cutaneous  surfaces.  The  most  frequent  sites  are  the  tonsils, 
pharynx,  palate,  nares,  larynx,  trachea,  or  bronchi,  and  less 
frequently  the  mouth,  gums,  lips,  oesophagus,  stomach,  and 
vagina. 

The  mucous  membrane  is  congested,  swollen,  and  infil- 
trated with  fibrin-serum  and  pus,  which  appear  on  its  free 
surface.  The  epithelial  cells  and  the  exuded  leucocytes 
die  and  undergo  hyaline  degeneration,  losing  their  nuclei — 
the  so-called  "  coagulation-necrosis  "  of  Weigert.  There 
may  be  necrosis  of  the  false  membrane,  and  of  the  stroma  of 
the  underlying  mucous  membrane  as  well,  which  may  be- 
come gangrenous  in  some  cases.  Erosion  of  large  arteries 
with  even  fatal  hemorrhage  may  result. 

If  the  patient  recovers,  the  false  membrane  sloughs  o^  en 
masse  or  by  gradual  disintegration,  superficial  ulcers  being 
usually  left.  If  the  ulcers  be  deep,  evident  cicatrization 
may  result.  Successive  crops  of  membrane  form  if  the 
false  membrane  be  forcibly  detached. 

In  the  false  membrane  are  found  the  characteristic  bacilli 
associated  with  a  variety  of  other  organisms,  especially 
streptococci  and  staphylococci,  which,  as  a  rule,  penetrate 
more  deeply  than  does  the  Klebs-Loeffler  bacillus. 

The  appearance  of  the  membrane  varies.  It  may  be  ad- 
herent, a  bleeding  surface  being  left  after  its  forcible  removal, 
or  it  may  be  shreddy  and  readily  detached.  It  may  be  thick, 
soft,  and  yellow,  or  it  may  be  thin  and  so  transparent  that 
it  can  hardly  be  seen  by  the  naked  eye,  and  in  some  cases 
there  may  be  evident  only  a  localized  hyper£emia.  It  may 
be  of  a  dirty-green  color,  or  it  may  be  putrid  and  gangren- 
ous. The  surrounding  mucous  membrane  is  congested  and 
inflamed.  These  appearances  are  identical  with  those  of 
pseudo-diphtheritic  membranes,  the  only  point  of  difference 
being  the  presence  of  the  Klebs-Loeffler  bacilli  in  the  true 
cases. 

Complicating  lesions  are  variable.  There  may  be  adenitis 
of  the  lymphatic  glands  near  the  infected  area,  which  may 
proceed  to  suppuration  from  mixed  streptococcus  infection. 
The  periglandular  tissues,  and  even  the  salivary  glands,  may 
become  in  like  manner  affected.     Bronchitis,  either  catarrhal 


96  M.tXrAL    OF   THE   FKACTICE    OF  MEDICIXE. 

or  diphtheritic,  areas  of  atelectasis,  and  patches  of  broncho- 
pneumonia are  usually  present  in  fatal  cases.  There  may- 
be endocarditis  in  rare  cases,  but  an  acute  degeneration  of 
the  heart-muscle  is  not  uncommon  and  may  lead  to  sudden 
death. 

The  kidneys  may  be  the  seat  of  an  acute  degeneration  or 
of  an  exudative  or  a  diffuse  nephritis.  The  spleen  may  be 
found  large  and  soft.  In  cases  fatal  from  asphyxia  the 
viscera  are  usually  congested. 

Incubation  may  occupy  from  one  to  fourteen  days,  the 
average  duration  being  from  two  to  five  days. 

The  symptoms  may  be  divided  into  two  groups  :  i.  Gen- 
eral SN^mptoms  due  to  the  ptomaine-poisoning,  and  which 
are  the  same  in  all  cases ;  2.  Local  svi/iptoiiis,  which  vary 
according  to  the  localization  of  the  lesion. 

I.  General  Symptoms. — In  some  cases  the  disease  begins 
abruptly  with  a  chill  or,  in  children,  with  convulsions.  Usu- 
ally, however,  the  onset  is  insidious,  being  marked  by  pros- 
tration, fever,  and  often  by  digestive  disturbances. 

The  fever  does  not  run  a  typical  course ;  it  may  be  as 
high  as  104°  F.,  but  a  temperature  of  from  101°  to  103°  F. 
is  more  common.  It  is  often  irregular  or  intermittent,  and 
possibly  is  altogether  absent  even  in  fatal  cases. 

Prostration  is  an  early  and  constant  symptom,  and  is 
proportioned  more  to  the  actual  gravity  of  the  case  than 
to  the  height  of  the  fever  or  to  the  local  lesion.  In  mild 
cases  prostration  may  be  slight  or  absent.  The  pulse  is 
rapid,  with  a  tendency  to  become  feeble  according  to  the 
severity  of  the  disease.  In  some  cases  the  pulse  may  be 
slow  (50  to  60) ;  this  is  not  usually  a  favorable  sign.  At 
any  time  sudden  or  gradual  heart  failure  may  develop,  even 
during  advanced  convalescence.  This  makes  the  prognosis 
uncertain  in  every  case. 

Sudden  heart  failure  will  be  followed  by  almost  instanta- 
neous death.  Gradual  heart  failure  will  be  shown  by  increas- 
ing rapidity  and  weakness  of  the  pulse,  dyspnoea,  cyanosis, 
and  congestion  of  the  different  viscera,  with  death  in  a  itv^ 
hours  or  days. 

Cerebral  symptoms  comprise  stupor,  often  alternating  with 


DirnrHERfA.  97 

restlessness,  or  mild  delirium  or  convulsions,  semi-coma,  and 
coma.  These  symptoms  are  rather  rare  considering  the 
severely  toxic  character  of  the  disease.  They  may  appear 
early,  from  the  toxic  action  of  the  ptomaines  on  the  nervous 
centres,  or  they  may  appear  late,  as  the  result  of  asphyxia. 

In  some  cases  there  appears  an  erythematous  eruption 
resembling  that  of  scarlatina.  It  is,  however,  evanescent, 
fading  usually  in  a  few  hours.  Bacterial  examination  of 
the  pseudo-membrane  or  the  exudate  may  be  necessary  to 
differentiate  between  this  disease  and  those  cases  of  scar- 
latina complicated  with  pseudo-diphtheritic  pharyngitis. 
In  malignant  cases  there  may  be  purpura.  Albuminuria 
occurs  in  the  majority  of  severe  cases,  from  parenchj'ma- 
tous  degeneration  of  the  kidney.  The  occurrence  of  a  true 
nephritis  must  be  considered  as  a  complication. 

2.  Local  Symptoms. — (a)  Tonsillar  Diphtheria. — This  is 
the  commonest  form  of  diphtheria,  and  at  the  same  time  the 
least  serious.     There  are  three  clinical  forms : 

(i)  There  is  a  pseudo-membrane  on  one  or  both  tonsils, 
having  no  relation  to  the  crypts.  (2)  The  crypts  of  the 
tonsils  are  filled  with  a  pseudo-membranous  exudate  which 
appears  on  the  surface  as  white  points,  resembling  in  every 
way  the  appearances  presented  by  ordinary  follicular  tonsil- 
litis, and  from  which  it  can  be  differentiated  only  by  bacterial 
examination.  These  white  points  in  some  cases  may  so 
coalesce  that  the  tonsils  are  covered  with  irregular  white 
patches.  (3)  The  tonsil  swells ;  there  are  swelling  and 
oedema  of  the  surrounding  structures,  resembling  the  ap- 
pearances of  ordinary  suppurative  peritonsillitis  or  quin.sy. 
No  membrane  is  visible  until  after  thirty-six  to  forty-eight 
hours.  These  cases,  which  seem  to  be  due  to  bacterial 
invasion  of  the  deeper  structures,  are  apt  to  do  badly. 

The  local  symptoms  of  the  first  two  varieties  are  apt  to  be 
mild,  lasting  but  a  few  days.  There  may  be  moderate  fever; 
prostration  is  slight  or  absent ;  the  voice  is  muffled  ;  there  are 
pain  and  soreness,  which  are  increased  by  talking  or  SAval- 
lowing. 

However  mild  the  case,  the  disease  may  spread  and 
become  severe,  or  it  may  be  followed  by  any  of  the  com- 


98  MA.VL-JL    OF  THE   PRACTICE    OF  MEDICIXE. 

plications  or  sequel.x,  and  it  may  be  the  cause  of  infecting^ 
others  even  with  the  most  severe  forms. 

(/;)  P]iarvngcal  DiplitJicria. — (i)  There  may  only  be  an  area 
of  local  hyper^emia  without  any  pseudo-membrane.  This 
condition  is  seen  in  those  exposed  to  diphtheria,  and  is 
commonly  called  "  sympathetic  sore  throat."  It  is  really 
diphtheritic,  however,  and  may  not  only  be  followed  by 
sequelae  or  the  spread  of  the  disease,  but  may  even  be  the 
source  of  contagion  to  others. 

(2)  There  may  be  a  pseudo-membrane  evident,  usually 
associated  with  membrane  on  the  tonsils. 

Symptoms. — In  mild  cases  there  may  only  be  malaise, 
slight  fever,  and  a  raw  feeling  in  the  throat.  In  severer 
cases  there  may  be  pain,  increased  b\'  talking  or  by  swallow- 
ing, muffled  voice,  fetid  breath,  and  in  some  cases  ptyalism. 

(3)  Nasal  diphtheria  is  rare  as  a  primary  form,  being  usu- 
ally secondary  to  membrane  in  the  pharynx.  From  the  for- 
mation of  pseudo-membrane  in  the  nasal  cavities  and  the 
attendant  swelling  of  their  mucous  membranes  the  nostrils 
become  more  or  less  occluded.  There  is  usually  a  dis- 
charge from  the  nose  of  muco-pus  or  sero-pus,  which  may 
be  stained  with  blood.  In  some  cases  there  is  a  brown, 
watery  discharge  which  stains  the  pillow  and  excoriates  the 
hps. 

The  glands  of  the  neck  are  more  often  involved  in  naso- 
pharyngeal diphtheria  than  in  any  other  form,  considerable 
deformity  usually  resulting  from  their  tumefaction. 

If  the  nose  be  involved,  the  patient  is  apt  to  do  badly. 
Death  usually  results  from  sepsis  with  cerebral  symptoms 
or  from  heart  failure.  Small  babies  either  asphyxiate  or 
starve  Trom  their  inability  to  breathe  if  they  are  nursed, 
unless  they  are  fed  by  the  stomach-tube. 

(4)  Laijngcal  diphtheria  is  a  common  form,  and  is  greatly 
dreaded  for  the  following  reasons : 

{a)  There  is  apt  to  be  asphyxia  from  the  occlusion  of  the 
glottis  by  pseudo-membranes,  by  the  swelling  and  oedema 
of  the  vocal  cords,  and  in  some  cases  by  their  paralysis, 
from  the  projection  of  little  tongues  or  tags  of  loose  pseudo- 


DJPI/'l'JJKRfA.  99 

membrane  into  the  rima  glottidis,  and  by  the  spasm  from 
time  to  time  of  the  laryngeal  muscles. 

{J})  As  the  larynx  is  seldom  infected  primarily,  but  is 
affected  from  the  spread  of  the  disease  from  the  pharynx, 
the  pseudo-membrane  is  apt  to  be  extensive  and  toxaemia 
severe. 

(c)  The  pseudo-membrane  is  apt  to  spread  downward  and 
to  involve  the  trachea  and  the  bronchi. 

id)  There  is  apt  to  be  developed  either  septic  broncho- 
pneum.onia  or  "  deglutition-pneumonia  "  or  areas  of  atelec- 
tasis. 

{e)  Because  the  larynx  is  affected  usually  in  children,  who 
do  not  stand  the  disease  well. 

Symptoms. — The  voice  is  hoarse  and  croupy,  and  may  be 
reduced  to  a  faint  whisper.  There  is  a  hoarse,  croupy 
cough.  The  breathing  is  rapid  and  inefficient,  and  there  is 
obstructive  dyspnoea  which  may  be  either  obvious  or 
masked. 

In  obvious  dyspnoea  the  child  sits  up  with  the  neck  craned 
forward,  to  bring  into  play  all  the  accessory  muscles  of 
respiration.  The  alae  nasi  dilate;  inspiration  is  prolonged  and 
stridulous.  There  is  inspiratory  sinking  of  the  spaces  above 
and  below  the  clavicles.  The  face  is  anxious  and  distressed, 
and  may  be  semi-cyanotic.  From  time  to  time  there  occur 
paroxysms  of  increased  dyspnoea  that  are  often  relieved  by 
coughing  up  pieces  of  pseudo-membrane.  Unless  the  con- 
dition is  relieved  by  the  casting  off  of  the  pseudo-mem- 
brane or  by  operative  interference,  the  child  passes  into  the 
condition  of  masked  dyspnoea. 

In  masked  dyspnoea  the  child  no  longer  struggles  for 
breath,  but  lies  flaccid  or  in  a  stupor  which  may  deepen  into 
coma.  The  skin  becomes  cold  and  livid,  the  pulse  becomes 
more  rapid  and  feeble.  In  this  condition  the  patient  may 
remain  for  from  one  to  four  days,  and  recovery  from  this 
stage  is  exceedingly  rare.  All  cases,  however,  do  not  pass 
into  this  stage,  but  after  a  time  the  pseudo-membrane  be- 
comes loosened  and  is  coughed  up  either  in  large  pieces  or 
by  gradual  disintegration.  Glandular  swellings  are  not 
seen  jn  diphtheria  of  the  larynx  alone. 


lOO        MA.VL'AL    OF  THE  PKACTICE    OF  MEDICINE. 

Complications  and  Sequelae. — Local  complications  have 
already  been  alluded  to.  They  are  sloughing,  erosion  of 
arteries  with  hemorrhage,  and  swelling  of  the  neighboring 
glands. 

Pulmonary  complications  occur  in  almost  all  fatal  cases, 
and  present  their  ordinary  symptoms  and  physical  signs. 
Should  pneumonia  occur  in  very  sick  patients,  its  symptoms 
are  frequently  masked  by  those  of  the  primary  disease. 

There  may  be  gastritis  or  enteritis.  Renal  complications 
are  common. 

Acute  parenchymatous  degeneration  shows  itself  by 
changes  in  the  urine  alone.  Acute  exudative  or  acute  dif- 
fuse nephritis  may  occur  during  the  disease  or  during  con- 
valescence. There  are  the  changes  in  the  urine  common  to 
such  lesions  ;  there  may  be  suppression  with  uraemic  symp- 
toms. In  some  patients  much  exhausted  by  the  disease 
uraemic  symptoms  may  not  appear. 

Of  the  sequelae,  peripheral  neuritis  is  the  most  important. 
It  is  seen  in  from  lo  to  40  per  cent,  of  all  cases,  according 
to  the  epidemic,  and  usually  occurs  in  the  second  or  third 
week  of  convalescence.  It  may  follow  either  mild  or  severe 
cases. 

The  muscles  most  frequently  paralyzed  are  those  of  the 
soft  palate.  The  voice  becomes  nasal,  there  is  inability  to 
clear  the  throat,  and  deglutition  is  interfered  with,  fluids 
regurgitating  through  the  nose.  This  may  be  the  only 
symptom.  The  patient  may  have  to  be  fed  through  the 
stomach-tube,  especially  if  the  paralysis  extend  to  the  con- 
strictors of  the  pharynx. 

The  next  most  common  forms  are  paralyses  of  the  eye- 
muscles.  The  intrinsic  muscles  may  be  affected,  causing 
dilatation  of  the  pupil  and  loss  of  power  of  accommodation. 
The  involvement  of  the  extrinsic  muscles  produces  ptosis 
and  strabismus. 

If  the  nmscles  of  the  larynx  be  affected,  there  will  result 
dysimoea,  aphonia,  and  a  croupy  cough. 

More  rarely  the  muscles  of  one  or  more  extremities  may 
become  paralyzed,  or  there  may  only  be  some  weakness 
in  the  legs  with  loss  of  tendon-reflex. 


Dfi'irrifF.k'iA.  loi 

Diphtheritic  paralysis  usually  lasts  but  a  few  weeks  or 
months,  terminating  in  recovery,  although  in  some  cases 
it  may  become  permanent. 

The  nephritis  may  become  chronic  and  lead  to  the  death 
of  the  patient.  There  may  be  resulting  endocarditis.  If 
the  conjunctivae  be  the  seat  of  a  pseudo-membrane,  ulcers 
of  the  cornea  with  opacities  usually  result. 

The  prognosis  is  always  serious,  and  must  in  all  cases 
be  made  guardedly,  because,  however  mild  the  attack  may 
be,  it  may  at  anytime  spread  and  become  severe.  The  dan- 
ger of  heart  failure  must  always  be  regarded.  The  progno- 
sis depends  upon  the  character  of  the  prevailing  epidemic 
and  also  upon  the  age  of  the  child,  42  per  cent,  of  cases 
being  fatal  before  the  fourth  year,  35  per  cent,  between  the 
fourth  and  tenth  years,  and  10  per  cent,  between  the  tenth 
and  twentieth  years.  The  average  mortality  is  about  25  per 
Cent.  The  prognosis  depends  not  only  upon  the  severity 
of  the  general  infection,  but  also  upon  the  locality  and  extent 
of  the  lesions,  being  worse  in  nasal,  laryngeal,  pharyngeal, 
and  tonsillar  cases  in  the  order  mentioned.  The  prognosis 
also  depends  upon  the  presence  of  complications  and  upon 
possible  sequelae.  As  a  rule,  a  good  prognosis  may  be 
given  to  cases  of  tonsillar  diphtheria  that  do  not  spread 
within  two  days. 

The  mortality  has  been  reduced  within  the  past  year, 
under  the  antitoxine  treatment,  to  just  one-half  the  former 
death-rate.  If  cases  can  be  treated  by  antitoxine  within 
the  first  thirty-six  hours,  the  mortality  will  still  further  be 
reduced. 

Treatment. — Prophylactic  Treatment. — Careful  isolation 
should  be  enforced,  not  only  for  the  patient,  but  also,  as 
far  as  possible,  for  the  attendants.  "  The  members  of  a 
household  in  which  a  case  of  diphtheria  exists  should  be 
regarded  as  sources  of  danger  unless  cultures  from  their 
throats  show  the  absence  of  virulent  diphtheria  bacteria " 
(Park).  Attendants  on  the  sick  should  receive  immunizing 
doses  of  antitoxine.  Isolation  should  be  continued  until  the 
bacilli  are  proved  to  be  absent.  In  one-half  the  cases  the 
bacilli  disappear  within  three  days  after  the  disappearance  of 


I02        MA.VL'AL    OF   THE   PKACT/CE    OF  .VFD/CIXE. 

the  pseudo-membrane ;  in  one-third  of  the  cases,  in  seven 
days  ;  in  one-tenth  of  the  cases,  in  fourteen  days  ;  while  the 
bacilli  max-  remain  in  a  small  percentage  of  cases  as  late  as 
the  sixty-third  day.  After  isolation  is  relaxed,  the  room, 
with  the  bedding,  toys,  etc.,  should  be  fumigated  thoroughly 
with  sulphur,  and  the  linen  should  be  boiled  in  2  per  cent, 
carbolic  solution.  The  w^alls  and  the  floors  should  be 
scrubbed  with    i  :  lO.OOO  bichloride  solution. 

General  Treatment. — The  child  should  be  put  to  bed  and 
be  kept  on  a  milk  diet.  The  temperature  of  the  room 
should  be  70°  F.,  and  the  air  should  be  kept  moist.  The 
use  of  the  steam-tent  will  be  alluded  to.  Careful  attention 
should  be  paid  to  the  heart,  and  stimulants  should  be  given 
freely  when  required.  Especially  are  alcoholic  stimulants 
to  be  recommended.  The  danger  of  heart  failure  during 
early  convalescence  should  not  be  forgotten.  The  temperature 
may  be  controlled,  if  necessary,  by  hydrotherapy.  Internal 
antipyretics  should  be  avoided.  Large  repeated  doses  of 
the  tincture  of  the  chloride  of  iron  (4  to  5  drops  hourly 
to  a  child  of  three  years)  and  the  use  of  corrosive  sublimate 
in  small  doses  (gr.  -^  every  four  hours  as  a  limit,  or  gr.  -gL. 
every  hour)  have  been  recommended  warmly.  The  former 
is  recommended,  with  alcoholic  stimulants,  as  a  routine  treat- 
ment. Chlorate  of  potash  should  not  be  emplo}xd,  because 
of  its  evil  effect  upon  the  kidneys. 

Local  Treatment. — As  diphtheria  is  a  local  disease  at  first, 
the  bacilli  growing  in  the  pseudo-membrane  and  elaborating 
there  the  toxalbumins  that  poison  the  system,  local  treat- 
ment becomes  of  the  first  importance  in  destroying  the  activ- 
ity of  the  germ  and  in  removing  the  toxalbumins  when 
formed.  Rough  treatment  and  the  mechanical  tearing  off 
of  the  pseudo-membrane  are  of  actual  harm.  The  best 
treatment  consists  in  the  thorough  irrigation  of  the  throat 
and  nose  with  a  neutral  salt-solution  (3j  to  Oj)  or  with 
boric-acid  solution,  a  tablespoonful  to  the  pint.  A  foun- 
tain syringe  should  be  used,  and  the  fluid  should  be  at  a 
temperature  of  85°  F.  The  patient  lying  on  the  side  (as 
in  Plate  9),  the  nozzle  of  the  irrigator  should  be  inserted 
in  the  upper  nostril   until  the  fluid  runs  out  of  the  other 


DiprrniERiA. 


Pl.A'l  K  9. 


Irrigation  of  naso-pharynx  (Berg). 


DIPIITUERIA.  103 

nostril  and  the  mouth.  Then  the  process  is  repeated  with 
the  lower  nostril.  The  tip  of  the  irrigator  should  then  be 
passed  well  back  over  the  dorsum  of  the  tongue,  and  the 
pharynx  well  flushed  out.  In  case  the  nostrils  be  occlud- 
ed with  membrane,  the  fountain  syringe  may  be  elevated 
six  or  eight  feet.  Such  irrigation  should  be  done  every 
two  hours.  In  septic  cases  irrigation  with  bichloride 
(i  :  4000  to  I  :  8000)  may  be  employed  every  four  to  eight 
hours  in  addition.  If  the  membrane  be  thick,  insufflations 
of  papoid  powder  may  be  used  to  advantage.  Other  local 
remedies  have  been  recommended,  but  are  not  now  as  much 
used  as  formerly.  Among  these  remedies  are  insufflations 
of  powdered  sulphur,  applications  of  tincture  of  the  chlo- 
ride of  iron,  iodine,  peroxide  of  hydrogen,  trypsin,  and 
lactic  acid. 

So  high  an  authority  as  Loeffler  recommends  the  follow- 
ing method  of  local  treatment :  After  cleansing  the  surface 
of  the  pseudo-membrane  the  following  solution  is  to  be  ap- 
plied on  cotton  swabs  for  ten  seconds  every  three  hours, 
later  three  times  a  day : 

3^.  Alcohol,  60  volumes  ; 

Toluol,  36  volumes  ; 

Liq.  ferri  sesquichlorati,  4  volumes  ; 

Menthol,  20  volumes. 

In  laryngeal  diphtheria  with  dyspnoea  two  additional  rem- 
edies are  warmly  recommended — the  steam-tent  and  calo- 
mel fumigation. 

The  steam-tent  should  be  used  upon  the  first  appearance 
of  dyspnoea,  but  it  may  be  used  in  any  case  as  a  routine 
measure.  A  good  way  to  form  the  tent  is  to  throw  sheets 
over  clothes-horses  arranged  about  the  bed,  or  to  suspend 
from  the  ceiling  an  open  umbrella  about  which  the  sheets 
can  be  draped.  The  nozzle  of  a  steam-kettle  should  be  in- 
serted within  the  tent,  so  that  the  air  is  kept  constantly 
moist. 

Calomel  inhalations  have  been  employed  in  laryngeal  diph- 
theria, especially  with  dyspnoea  :  10  to  20  grains  may  be  used 


104 


MAXr.lL    OF   THE   PRACTICE    OF  MEDICLXE. 


evci")-  two  to  four  hours  without  dant^cr  of  salivation  to  a 
child,  although  the  nurses  may  suffer  from  sore  gums  ;  mer- 
curic diarrhoea  may,  however,  occur.  The  calomel  should 
be  piled  on  a  piece  of  tin  resting  upon  the  sides  of  a  small 

pail  or  chamber  utensil,  un- 
der the  centre  of  the  tin  be- 
ing the  alcohol  lamp  (Fig.  i)_ 
The  whole  apparatus  is  to  be 
placed  inside  the  croup-tent, 
and  care  must  be  exercised 
that  the  child  does  not  kick 
the  lamp  over  and  set  fire 
to   the  bedding. 

When  the  laryngeal  pseudo- 
membrane  is  being  loosened, 
Fig.  I.— Method  of  fumigating  with  caio-  its  Separation   may   be  hast- 

mel  :   a,  pail   (section);   b,  alcohol;  c,  strip       „     j     u  >.•  u  i.i 

f,    ,,       ,    .,     Y  ,      ,       ,  ened   by  emetics;    but  these 

of  bent  tin  ;  a,  pile  of  calomel  powder.  -'  ' 

are  not  to  be  recommended 
except  in  robust  cases  with  good  heart-action,  in  whom 
dyspnoea  appears  due  to  the  obstruction  caused  by  the  loose 
membrane  and  the  mucous  secretion. 

When  actual  obstructive  dyspnoea  begins  the  question  of 
operative  interference  comes  into  consideration.  For  the 
details  of  intubation  and  tracheotomy  the  reader  is  referred 
to  works  on  surgeiy.  It  seems  that  intubation  should  be 
our  first  choice,  and  it  should  be  done  as  soon  as  cyanosis, 
restlessness,  and  sinking  of  the  intercostal  spaces  are  noticed 

Serum-therapy. — The  growth  of  the  Klebs-Loefifler  bacillus 
(Plate  lo)  in  the  body-tissues  develops  the  peculiar  toxalbu- 
min  to  the  poisoning  from  which  the  constitutional  symptoms 
are  due.  Nature  in  some  unknown  way  elaborates  in  the  body 
an  antidotal  poison,  the  antitoxine,  and  when  the  two  poisons 
balance  in  effect  the  constitutional  symptoms  cease  and  the 
patient  recovers.  If  antitoxine  can  be  made  outside  the 
body,  and  injected  when  needed,  in  sufficient  doses,  without 
waiting  for  the  system  to  elaborate  it,  the  disease,  it  was 
thought,  might  be  stamped  out  at  the  onset.  The  growing 
experiences  of  the  past  year  tend  more  and  more  to  prove 
the  correctness  of  this  assumption. 


DIl'inilERIA. 


ri.ATF,  lO. 


~M_:! 


M...  A.J 


I.  Klebs-Loeffler  bacillus  (photographed  by  Dr.  W.  H.  Park).     2.   Hutchinson  teeth. 


DIPJJ'J'JIKRfA. 


loi; 


We  may  obtain  the  toxine  of  the  Klebs-Locffler  bacillus 
by  growing  it  in  a  suitable  culture-medium,  and  by  injecting 
it  in  increasing  amounts  into  an  animal  susceptible  to  diph- 
theria, such  as  the  horse.  The  serum  of  the  horse's  blood 
will  gradually  become  saturated  with  the  newly  developed 
substance,  which  is  antidotal  to  the  toxine.  This  may  be 
withdrawn,  separated  as  far  as  possible  from  the  rest  of  the 
blood,  preserved  by  the  addition  of  certain   substances,  or 


DATE 

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Fig.  2. — Chart  of  diphtheria  treated  by  antitoxine  (.Fischer). 

dried,  and  given  the  name  of  diphtheria  antitoxine.  Its 
strength  is  determined  experimentally  as  follows  :  From  a 
solution  of  Klebs-Loeffler  toxine  inject  into  a  guinea-pig  of 
a  certain  weight  just  enough  to  kill  it.  Into  others  of  the 
same  weight  inject  different  amounts  of  antitoxine,  and  then 
observe  how  much  was  required  to  neutralize  the  effect  of  the 
toxine.  Assuming  a  certain  weight  of  guinea-pig  as  a  unit,  we 
can  easily  determine  the  strength  of  the  toxine  or  antitoxine. 
The  Klebs-Loeffler  antitoxine  does  not  seem  to  be  poison- 


I06        M.lXrAL    OF   THE    PRACTICE    OF  MEDIC  LYE. 

ous  to  the  human  ori,^ani.sm  in  any  doses  thus  far  given, 
unless  we  except,  perhaps,  a  few  rare  cases  of  individual 
susceptibility,  such  as  is  seen  in  an}^  medication.  It  is  a 
remedial  agent  of  great  potency  in  diphtheria,  w^th  the  fol- 
lowing limitations  :  It  cannot  repair  any  cell  damage  already 
done,  nor  can  it  neutralize  the  toxines  of  other  bacteria  so 
often  complicating  diphtheria,  such  as  the  Streptococcus 
pyogenes.  Neither  can  it  nullify  the  ptomaines  produced  by 
the  necrosing  tissue  in  the  local  lesion.  However,  the  great 
reduction  of  mortality  by  its  partial  inhibition  of  the  growth 
of  the  bacillus  in  the  lesion,  and  its  complete  neutralization 
of  the  Klebs-Loeffler  toxine  when  in  contact,  justify  us  in 
its  use  in  every  case  of  Klebs-Loeffler  diphtheria  whenever 
we  have  reason  to  think  there  is  free  toxine  circulating  in 
the  blood.  Inasmuch  as  it  cannot  repair  damage  already 
done,  the  earlier  in  the  disease  it  is  given  the  better. 

Frequently  after  its  use  a  temporary  urticaria  of  the  skin 
will  develop.  Other  drugs,  such  as  quinine,  also  produce 
this  lesion.  Other  occasional  rashes  which  have  been  de- 
scribed as  due  to  its  use  are  probably  caused  by  impurities. 

It  is  given  at  present  by  hypodermic  injection  into  the 
looser  subcutaneous  tissues  with  the  usual  aseptic  precau- 
tions. The  frequency  and  quantity  used  are  still  somewhat 
experimental.  Ordinarily  a  child  receives  looo  to  2000 
units,  and  an  adult  1500  to  10,000  units  (usuallj'  2000), 
repeated  as  often  as  may  be  necessary.  The  volume  used 
depends  on  the  strength  of  the  solution.  An  immunizing 
dose  is  said  to  be  500  units. 

It  is  believed  that  recovery  should  take  place  in  all 
patients  treated  within  the  first  twenty-four  hours.  Taking 
all  the  cases  together,  the  mortality  has  been  materially 
reduced,  and  with  improved  methods  and  improved  ap- 
preciation of  the  value  of  early  diagnosis  and  early  treat- 
ment the  mortality  will  still  further  be  reduced. 

ERYSIPELAS. 
Definition. — Erysipelas  is  an  infectious  inflammation  of 
the  skin  with  constitutional  symptoms,  caused  by  the  inocu- 
lation of  the  streptococcus  erysipelatosus. 


ERYSIPELAS.  10/ 

Etiology. — The  disease  is  due  to  infection  of  the  lym- 
phatics of  the  skin  by  a  streptococcus  which  is  identical 
in  appearance  with  the  streptococcus  pyogenes.  Infection 
always  occurs  through  wounds  or  abraded  surfaces,  intact 
skin  and  mucous  membranes  affording  absolute  protection. 
Two  forms  are  usually  described — {a)  a  tratimatic  form 
complicating  surgical  wounds  and  injuries,  and  {6)  an  idio- 
pathic form  occurring  usually  in  the  face,  in  which  no  trau- 
matic point  of  origin  can  be  found.  The  only  real  differ- 
ence between  these  two  forms  is  that  in  the  one  the  point 
of  entrance  is  apparent,  while  in  the  other  it  is  slight  and  is 
usually  overlooked.  The  disease  is  favored  by  poor  hygiene, 
by  bad  plumbing,  and  by  contact  with  infected  cases.  As 
inoculation  through  abraded  surfaces  is  necessary  to  cause 
the  disease,  it  cannot  be  considered  as  contagious  in  the 
ordinary  acceptation  of  the  term.  It  is  commonest  in  alco- 
holic and  debilitated  patients  and  in  those  suffering  from 
Bright's  disease.  One  attack  does  not  secure  immunity. 
Some  patients  are  exceedingly  susceptible  and  may  suffer 
from  repeated  attacks. 

Patholog-y. — Erysipelas  is  really  a  progressive  lymph- 
angitis of  the  skin  involving  the  perilymphatic  tissues  by 
continuity.  There  is  an  infiltration  of  the  cutis  vera  by 
fibrin  serum  and  leucocytes  ;  this  infiltration  in  severe  cases 
may  extend  to  the  subcutaneous  connective  tissue.  The 
lymphatics  are  crowded  with  the  streptococci,  especially  at 
the  margin  of  the  patch  and  extending  into  the  healthy 
skin.  Vesicles  and  bullae  may  be  formed.  Suppuration 
does  not  occur  unless  there  be  an  added  infection  by  pus 
microbes. 

Symptoms  begin  from  fifteen  to  sixteen  hours  after  inoc- 
ulation. 

General  Symptoms. — The  disease  usually  is  initiated  by  a 
chill  and  a  rise  of  temperature  to  103°  or  104°  F.  or  even 
higher.  Nausea  and  vomiting  are  common  at  the  onset. 
The  pulse  is  full  and  bounding,  and  is  rarely  over  100  except 
in  the  most  severe  forms  or  in  debilitated  and  alcoholic  sub- 
jects. In  these  cases  the  pulse  may  become  rapid  and  feeble 
and  may  be  a  source  of  real  danger. 


I08        MAXC.U.    OF   THE  PRACTICE    OF  MEDICLXE. 

Delirium  belongs  to  the  severer  cases,  and  is  especially 
marked  in  alcoholic  patients.  It  may  be  either  mild  and 
maniacal  or  low  and  muttering.  There  is  usually  severe 
headache,  especially  in  erysipelas  of  the  face  and  scalp. 
Prostration  is  marked  in  proportion  to  the  severity  of  the 
disease.  There  may  be  albuminuria.  In  fatal  cases  the 
patient  may  pass  into  a  "  typhoid  condition." 

The  constitutional  symptoms  may  be  mild,  such  as  would 
be  due  to  a  slight  local  inflammation,  or  the}'  may  be  ex- 
ceedingly well  developed,  resembling  those  caused  by  any 
severe  general   infection. 

Local  SjJiiptoiiis. — The  skin  becomes  swollen  and  shiny 
and  of  a  rose  color  which  disappears  on  pressure.  It  is  dis- 
tinctly thickened  and  indurated.  The  patient  complains  of 
feelings  of  tension,  burning,  and  itching.  The  swelling  is 
most  marked  in  places  where  there  is  considerable  loose 
connective  tissue,  as  in  the  face  or  the  eyelids,  and  in  these 
localities  there  is  also  considerable  oedema.  Inflammatory 
changes  are  more  marked  at  the  border  of  the  eruption, 
which  is  abrupt  and  elevated  and  shows  tongue-like  pro- 
longations projecting  into  the  healthy  skin.  These  cha- 
racteristics of  the  border  of  the  patch  are  distinctive  and 
absolutely  diagnostic.  In  some  cases  there  appear  vesicles 
or  bullae. 

If  there  be  an  added  infection  by  the  ordinary  pus 
microbes,  the  contents  of  the  vesicles  or  the  bullae  may  be- 
come purulent,  or  there  may  be  complicating  phlegmonous 
inflammation  of  the  deeper  structures  of  the  skin,  or  meta- 
static abscesses  of  internal  viscera,  or  septic  inflammation 
of  any  of  the  serous  membranes.  In  some  cases  the  local 
inflammation  is  so  intense  that  superficial  gangrene  results. 
Exfoliation  of  the  skin  usually  follows  the  subsidence  of  the 
eruption. 

When  the  disease  once  begins,  it  is  common  for  it  to 
spread  from  the  periphery,  so  that  large  surface  areas  may 
become  successively  involved.  Its  progress  may  be  checked 
by  any  decided  fold  in  the  skin,  particularly  the  naso-labial 
fold.  It  is  frequently  limited  at  the  border  of  the  hairy 
scalp.     In  facial  erysipelas  the  chin  and  the  anterior  aspect 


ERYSIPELAS.  lOQ 

of  the  neck  are  never  affected.  In  some  cases  erysipelas 
shows  a  tendency  to  creep  from  place  to  place,  subsiding 
in  the  old  situations  while  new  areas  are  constantly  becom- 
ing invaded.  In  this  way  it  may  spread  over  most  of  the 
body  and  the  extremities.  This  form  is  often  described  as 
"erysipelas  migrans."  In  other  cases  the  erysipelatous 
inflammation  may  attack  a  part  far  separated  from  the  pri- 
mary seat  of  infection.  This  condition  may  result  either 
from  infective  embolism  or  by  auto-inoculation,  the  cocci 
being  carried  from  the  primary  site  and  being  inoculated 
through  a  scratch  or  an  abrasion  into  the  distant  part.  These 
cases  are  designated  "  metastatic  erysipelas." 

If  the  streptococci  obtain  entrance  to  the  lymphatics  of 
the  post-partum  uterus,  the  most  virulent  and  fatal  form 
of  puerperal  sepsis  results. 

The  ptomaines  of  the  erysipelas  streptococci  often  exert 
a  favorable  effect  on  neoplasms,  causing  destruction  of 
tumor-cells.  Cases  of  cure  of  sarcoma,  carcinoma,  lupus, 
lipoma,  and  keloid  have  been  reported.  This  effect  may  be 
produced  either  by  an  attack  of  erysipelas,  accidentally  or 
purposely  induced,  or  by  subcutaneous  injections  of  the 
filtered  or  sterilized  cultures  of  the  streptococci  into  or  near 
the  tumor.  Attacks  of  erysipelas  in  patients  suffering  from 
diphtheria  have  often  exerted  a  beneficial  effect  on  that 
disease. 

Complications  are  most  commonly  due  to  an  added  in- 
fection by  pus  microbes.  There  may  be  suppurative  cellu- 
litis or  suppurative  thrombo-pyelitis.  Metastatic  abscesses 
in  the  viscera  may  occur,  especially  in  the  brain  and  lungs. 
There  may  be  septic  inflammation  of  serous  membranes, 
meningitis  being  the  most  important,  due  usually  to 
infection  through  the  sheaths  of  blood-vessels  or  nerves 
from  the  face.  There  may  be  ulcerative  endocarditis  or 
pericarditis.  Pleurisy  is  not  uncommon  with  erysipelas 
of  the  chest-wall.     Pneumonia  and  nephritis  are  infrequent. 

The  prognosis  is  usually  good  except  in  debilitated  sub- 
jects.    The  disease  is  usually  fatal  only  by  its  complications. 

Treatment. — Propliylactic . — The  patient  should  not  be 
attended  by  those  who  have  to  do  with  puerperal  or  surgical 


no        M.IXL'AL    OF  THE   PKACTICK    OF  MEDIC/XE. 

cases.  The  attendants  must  carefully  protect  any  abrasions 
on  their  own  persons,  and  must  cleanse  the  hands  frequently 
with  an  antiseptic  solution.  In  hospitals  the  patient  must 
be  isolated  and  the  ward  and  bedding  be  disinfected  care- 
fully. In  private  practice  rigid  isolation  is  not  so  neces- 
sary. 

General  ircatnioit  consists  in  careful  nursing  and  feeding 
and  in  controlling  annoying  or  threatening  symptoms  on 
general  principles.  Stimulants  may  be  given  freel}-  in  cases 
with  enfeebled  heart-action,  and  in  these  cases  the  admin- 
istration of  camphor  in  doses  of  gr.  i-ij  every  hour,  as 
recommended  by  Pirogoff,  has  been  found  serviceable.  As 
a  routine  treatment  tincture  of  the  chloride  of  iron  is  fre- 
quently given  in  large  doses  (Sss  in  glycerin  and  water  every 
two  to  three  hours),  but  it  does  not  seem  to  exert  any  spe- 
cific effect,  and  its  efficacy  is  doubtful. 

Local  ti'eatment  is  to  be  resorted  to  in  all  cases,  not  only 
to  relieve  the  local  symptoms,  but  also  to  check  further 
advance  of  the  disease.  Hueter  recommends  the  injection 
of  a  2  per  cent,  solution  of  carbolic  acid  under  the  healthy 
skin  near  the  advancing  border.  Injections  of  weak  solu- 
tions of  bichloride  or  biniodide  of  mercury  may  be 
employed  in  like  manner.  Kraske  recommends  multi- 
ple scarification  of  the  skin  in  advance  of  the  lesion,  with 
subsequent  moist  sublimate  dressings.  Painting  the  ad- 
vancing margin  twice  a  day  with  a  lo  per  cent,  solution  of 
carbolic  acid  in  alcohol  is  a  simple  measure,  and  the  result 
is  often  brilliant.  The  spread  of  the  disease  may  at  times 
be  checked  by  compression  of  the  healthy  skin  at  the  pe- 
riphery by  adhesive  straps. 

To  relieve  the  burning  and  itching,  applications  of  cold 
water,  of  solutions  of  acetate  of  alumina,  or  of  weak  car- 
bolized  or  sublimate  solutions  may  be  employed,  but  hot 
applications  are  generally  more  grateful  and  seem  to  exert 
a  beneficial  effect  upon  the  disease  itself  Hot  lead-and- 
opium  solution  or  any  of  the  above-mentioned  solutions 
may  be  employed.  Ichthyol  in  ointment  or  in  collodion, 
though  recommended,  is  not  of  much  service. 

Abscesses  and  suppurations  are  to  be  treated  without 
delay  on  general  surgical  principles. 


PYyEMIA.  Ill 

PYAEMIA. 

Definition. — Pyremia  is  a  septic  disease  characterized  by 
repeated  chills,  a  remittent  or  intermittent  temperature,  and 
metastatic  abscesses  in  various  parts  of  the  body,  due  to 
emboli  infected  by  the  microbes  of  pus. 

Etiology. — Pysemia  can  result  only  from  suppuration  in 
some  part  of  the  body,  the  microbes  of  suppuration  (strep- 
tococcus pyogenes  and  the  forms  of  staphylococci)  being 
necessary  for  its  development.  There  must  always  be,  in 
the  neighborhood  of  the  focus  of  suppuration,  an  inflamma- 
tion of  a  vein  due  to  the  invasion  of  its  wall  by  the  micro- 
organisms. This  phlebitis  is  regularly  followed  by  the  for- 
mation of  a  clot  in  the  interior  of  the  vein;  into  this  clot  the 
pus  microbes  make  their  way,  as  the  result  of  which  the  clot 
becomes  softened  and  breaks  down,  so  that  small  pieces 
containing  the  microbes  are  swept  into  the  general  circula- 
tion until  they  enter  some  vessel  too  small  to  allow  their 
passage.  Here  they  will  become  lodged,  and  as  the  nutri- 
tion of  the  part  suffers  from  the  cutting  off  of  its  blood-sup- 
ply by  the  emboli,  the  most  favorable  conditions  are  afforded 
for  the  development  of  metastatic  foci  of  suppuration. 

The  infecting  emboli,  to  get  into  the  arterial  circulation, 
must  first  pass  through  the  lungs,  which  act  as  filters. 
Hence  the  lungs  are  most  frequently  affected.  If  the  emboli 
enter  the  arterial  circulation,  they  may  cause  abscesses  in 
any  part  of  the  body.  This  is  the  case  also  in  malignant 
endocarditis,  in  which  disease  vegetations  from  the  diseased 
valves  containing  micro-organisms  become  detached,  are 
swept  into  the  arteries,  and  produce  metastatic  abscesses  in 
whatever  part  of  the  body  they  happen  to  lodge.  The  term 
"  arterial  pyaemia  "  is  often  used  to  designate  these  cases. 

Should  the  primary  focus  of  suppuration  occur  in  the 
district  of  the  portal  vein,  multiple  abscesses  of  the  liver 
are  produced,  and  there  may  be  also  suppurative  pyle- 
phlebitis. 

In  some  cases  the  primary  suppurative  focus  is  so  slight 
as  to  be  overlooked.  The  term  "idiopathic  pyaemia "  is 
used  to  designate  these  cases.     Osteomyelitis,  gonorrhoea. 


112        MAXL'AL    OF  THE   PRACTICE    OF  MEDICINE. 

and  prQstatic  abscess  are  the  conditions  most  frequently 
overlooked. 

Symptoms. — The  symptoms  of  septicaemia,  and  possibly 
the  local  symptoms  of  thrombosis  of  a  vein  near  the  sup- 
purating wound,  nia\-  precede  the  actual  symptoms  of  the 
disease. 

The  onset  is  marked  by  a  chill,  which  is  repeated  at  regu- 
lar or  irregular  intervals  throughout  the  disease.  The  tem- 
perature rises  rapidly  during  and  after  the  chill  to  103°  to 
105°  F.,  and  runs  an  intermittent  or  remittent  course,  its  fall 
being  accompanied  by  profuse  sweating.  There  may  be 
vomiting  and  diarrhoea.  The  pulse  becomes  rapid  and 
feeble,  and  there  is  rapid  emaciation.  Delirium  is  infrequent, 
the  mind  usually  being  clear  throughout  the  disease.  The 
breath  has  a  peculiar  sweetish  odor.  There  may  be  a  septic 
erythema  which  is  transitory.  The  face  may  be  pale  or 
there  may  be  developed  a  moderate  jaundice,  usually  of 
haematogenous  origin.  The  spleen  is  usually  large,  and  it 
may  be  painful  and  tender.  There  may  be  albumin  and 
blood  in  the  urine. 

The  symptoms  of  the  metastatic  abscesses  depend  upon 
their  number,  size,  and  locality.  Abscesses  in  the  lungs 
usually  give  rise  to  cough  and  dyspnoea. 

Any  of  the  serous  membranes  of  the  body  may  become 
secondarily  affected,  and  septic  involvement  of  the  joints 
(pysemic   rheumatism)  is  common. 

The  prognosis  is  always  grave.  Almost  all  patients  die 
in  a  few  weeks.  In  rarer  cases  the  disease  may  be  protracted 
for  months. 

Dia.gnosis. — The  three  conditions  with  which  this  dis- 
ease is  apt  to  be  confounded  are  malaria,  typhoid  fever, 
and  acute  miliary  tuberculosis. 

In  malaria  the  chills,  fever,  and  sweating  occur  with  more 
regular  periodicity,  are  checked  by  quinine,  and  in  the 
blood   the  plasmodium   malariae  can  be   found. 

A  careful  review  of  the  case,  the  occurrence  of  spots  and 
abdominal  symptoms,  and  the  course  of  the  disease  distin- 
guish it  from  typhoid  fever. 

In    acute    miliary   tuberculosis   the   s}-mptoms  are   more 


SErric.KMiA.  1 1 3 

those  of  septicaemia :  there  are  usually  evidences  of  tuber- 
cular foci,  and  bacilli  are  usually  present  in  the  sputum. 

Treatment  consists  in  the  aseptic  treatment  of  all  wounds, 
the  early  evacuation  of  abscesses  if  possible,  and  supporting 
the  strength  of  the  patient  by  feeding,  nursing,  and  the 
administration  of  alcoholic  stimulants  in  full  doses.  Qui- 
nine in  large  doses  may  be  found  of  temporary  benefit  in 
controlling  the  fever,  but  it  is  of  no  actual  service  in  modi- 
fying the  disease  itself 

SEPTICAEMIA. 

Definition  and  Synonym. — Septicaemia  is  the  train  of 
symptoms  resulting  from  the  introduction  into  the  circula- 
tion of  septic  micro-organisms  or  their  ptomaines.  Syn- 
onym :  Sepsis. 

Septicaemia  occurs  in  two  distinct  forms : 

1.  '^Septic  intoxication  is  caused  by  the  absorption  of  a 
pre-formed  ferment  or  toxine  which  produces  the  maximum 
effect  as  soon  as  it  reaches  the  circulation,  and  the  symp- 
toms subside  with  the  arrest  of  further  supply  and  the 
elimination  of  the  septic  material  from  the  circulation. 

2.  "  Septic  infection,  on  the  contrary,  occurs  in  conse- 
quence of  the  introduction  into  the  circulation  of  living 
micro-organisms  which  multiply  with  great  rapidity  in  the 
blood — a  circumstance  which  imparts  to  this  form  of  septi- 
caemia its  progressive  character  "  (Senn). 

Clinical  Forms. — i.  Fermentation  Fever  (Resorption 
fever,  Aseptic  fever,  or  After-fever)  is  that  form  of  septic  in- 
toxication which  results  from  the  absorption  of  the  products 
of  aseptic  tissue-necrosis.  It  follows  aseptic  wounds  or  in- 
juries, especially  if  strong  antiseptic  solutions  have  been  em- 
ployed, causing  necrosis  of  the  superficial  tissues.  It  may  fol- 
low transfusion  of  blood  or  of  simple  saline  solutions,  and  it 
has  been  produced  in  animals  by  the  intravenous  injection 
of  digestive  ferments.  It  frequently  follows  extravasations 
of  blood,  especially  if  they  be  confined  under  high  tension. 

Symptoms. — Within  several  hours  after  an  operation  or 
injury  the  temperature  rises  rapidly,  frequently  to  103°  or 
104°  F.,  subsiding  in  from  one  to  three  days.     Constitutional 


114        M.lXr.lL    OF  THE   PRAC'l'lCE    OF  MEDICIXE. 

symptoms  are  slight  or  absent.     The  earl)-  occurrence  of 
fever  drfiferentiates  tliis  from  the  remaining  forms  of  sepsis. 

2.  Sapr.emia  is  that  form  of  septic  intoxication  resulting 
from  the  absorption  of  the  products  of  putrefaction.  For 
its  development  three  conditions  are  necessarj^ :  (i)  Dead 
tissue,  as  clots  in  wounds  or  injuries,  retained  clots  or  prod- 
ucts of  conception  in  the  uterus  after  abortion  or  labor,  or 
tissues  devitalized  by  traumatism,  irritants,  or  the  action 
of  bacteria.  (2)  Infeclion  by  putrefactive  orgauisms  com- 
prising various  forms  of  bacteria  or  of  the  proteus  groups ; 
(3)  Sufficient  time  must  elapse  for  the  generation  and  absorp- 
tion of  ptomaines — at  least  twenty-four  hours. 

Syuiptouis. — The  first  symptom  is  usually  a  chill,  which  is 
followed  b\'  a  rise  in  temperature  to  102°  or  104°  F.  The 
pulse  becomes  rapid  and  weak,  depending  on  the  gravity 
of  the  case.  Cerebral  symptoms  are  common — headache, 
restlessness,  and  delirium.  Vomiting  and  diarrhoea  are 
almost  constant  in  grave  cases.  The  tongue  is  dry  and 
often  glazed,  and  may  assume  the  "  dried-beef"  appear- 
ance. The  intensity  of  the  symptoms  depends  on  the 
amount  of  absorbed  ptomaines. 

The  diagnosis  is  rendered  easy  by  the  detection  of  the 
putrefactive  focus  by  the  sense  of  smell,  fetor  being  constant. 

The  prognosis  depends  upon  the  amount  of  poison  ab- 
sorbed and  upon  the  possibilitN'  of  removing  the  putrefying 
dead  tissue  by  surgical  treatment. 

3.  Progressive  SEPXiCyEMiA  is  that  form  of  sepsis  caused 
not  only  by  the  absorption  of  ptomaines  produced  at  the 
site  of  the  primary  infection,  but  also  of  ptomaines  produced 
in  the  blood  from  the  microbes  which  it  contains.  The 
ordinary  pus  microbes  are  the  most  frequent  causes  of  this 
form  of  septicaemia. 

Symptoms  usually  arise  within  twenty-four  hours,  seldom 
as  late  as  the  third  day.  An  initial  chill  is  common.  The 
temperature  is  variable  :  usually  the  fever  begins  gradually, 
reaching  finally  103°  or  104°  F.,  and  often  it  is  intermittent 
or  remittent.  In  some  cases  the  temperature  may  be  subnor- 
mal. Prostration  is  an  early  symptom.  The  pulse  becomes 
rapid,  weak,   and   compressible.     There   is    usually   mental 


CHOLERA.  I  I  5 

apathy  and  indifference,  the  expression  being  stoHd.  There 
may  be  drowsiness,  stupor,  or  delirium.  The  face  is  pale  or 
of  a  yellowish  tinge.  Vomiting  and  diarrhoea  are  marked 
in  severe  cases.  The  tongue  is  dry,  red  at  the  edges,  black 
on  the  dorsum.  In  severe  cases  there  may  be  capillary 
hemorrhages. 

The  outlook  is  serious,  depending  upon  the  severity  of  the 
infection  and  the  possibility  of  an  early  disinfection  of  the 
primary  point  of  infection,  preventing  further  ingress  of 
microbes  into  the  circulation. 

Fatal  cases  rarely  last  longer  than  one  week,  and  in  most 
severe  forms  death  may  ensue  within  twenty-four  hours. 

CHOLERA. 

Definition  and  Synonym. — Cholera  is  an  acute  infectious 
disease  caused  by  the  comma  bacillus  and  characterized 
by  purging  and  collapse.     Synonym:  Asiatic  cholera. 

Etiology. — The  disease  is  endemic  in  India,  a  large  num- 
ber of  cases  occurring  every  year,  especially  at  the  places 
of  pilgrimage  along  the  banks  of  the  Ganges  and  Brahma- 
putra Rivers.  From  time  to  time  it  makes  epidemic  excur- 
sions to  all  civilized  countries,  where,  after  remaining  a 
certain  period,  the  epidemic  ceases  and  the  disease  is  found 
again  only  in  India.  Thus  in  1884-86  it  spread  from  India 
to  Egypt,  Italy,  Spain,  the  south  of  France,  Paris,  Hungary, 
and  the  Argentine  Republic  ;  it  then  disappeared,  reappear- 
ing in  1892  in  Persia,  whence  it  had  been  carried  from  India 
by  Mohammedan  pilgrims,  spreading  rapidly  to  Russia, 
Germany,  France,  and  Italy.  A  few  cases  brought  on  Ger- 
man and  Italian-  steamers  were  seen  in  New  York,  but  pro- 
tection was  afforded  by  strict  disinfection  and  quarantine. 

Epidemics  spread  along  lines  of  travel,  the  infection  being 
conveyed  not  only  by  those  suffering  from  the  disease,  but 
also  by  freight,  rags,  bedding,  etc.  which  have  become  con- 
taminated by  infected  fecal  discharges.  The  infection  is  not 
carried  by  the  air.  The  epidemics  travel  slowly,  and  they 
can  be  prevented  by  efficient  quarantine  and  disinfection. 
They  are  favored  by  poor  hj^giene,  especially  by  imperfection 
of  the  water-supply,  by.  dirty  habits,  and  by  the  crowding 


Il6        M.LXr.-tL    OF  THE    PK.ICT/CF.    OF  MKD/CLYE. 

together  of  people.  Any  condition  leading  to  diarrhoea  pre- 
disposes to  infection,  and  for  this  reason  the  epidemics  regu- 
larly are  more  severe  in  warm  seasons.  Cold  weather  may 
modify  an  epidemic  or  check  it  temporarily,  but  does  not 
entirely  eradicate  it. 

The  exciting  cause  is  a  bacillus,  the  "comma  bacillus" 
or  the  "bacillus  of  Koch."  This  bacillus  is  one-half  the 
length  of  the  tubercle  bacillus,  and  of  a  curved  or  letter  S 
shape.  It  is  really  a  spirillum.  It  can  readily  be  cultivated 
and  can  reproduce  the  disease.  It  is  killed  by  boiling,  by 
drying,  and  by  acids,  but  it  is  not  destroyed  by  freezing. 
It  occurs  in  the  intestinal  discharges  (though  not  when  the 
stools  become  normal,  nor  in  the  diarrhoea  of  convalescence), 
occasionally  in  the  vomita,  in  the  intestines  (whence  it  pene- 
trates into  the  intestinal  lymphatics),  and  in  the  submucosa. 

The  disease  is  not  personally  contagious,  as  it  can  occur 
onh'  when  the  germ  finds  access  to  the  intestinal  tract.  This 
entrance  is  accomplished  through  contaminated  water  or 
food.  Nurses  or  washerwomen  who  deal  with  soiled  bed- 
linen  and  who  are  uncleanly  as  to  their  hands  may  contam- 
inate their  food  in  this  way. 

Pathology. — There  are  no  characteristic  lesions  except 
the  presence  of  the  bacilli.  Bacteriological  examinations 
should  therefore  be  made  in  all  doubtful  cases.  The  body 
remains  warm  for  a  considerable  time,  and  there  is  a  marked 
post-mortem  rise  in  temperature.  Rigor  mortis  develops 
early  and  is  well  marked.  There  may  be  post-mortem 
movements  of  the  body,  arms,  or  legs.  All  the  tissues  are 
dry  and  anaemic ;  the  blood  is  dark  and  thick  ;  the  serous 
membranes  are  sticky,  dry,  and  may  be  coated  with  fibrin. 
The  mucous  membrane  of  the  stomach  and  intestines  may 
appear  normal  or  sodden  and  oedematous,  or  may  show 
traces  of  catarrhal  inflammation.  There  may  be  croupous 
colitis.  The  intestinal  glands  are  usually  swollen.  The 
intestines  contain  the  rice-water  discharge  or  a  dark  bloody 
fluid.  The  liver  is  anaemic  ;  its  cells  may  show  parenchym- 
atous degeneration.  The  kidney  is  the  seat  of  an  acute  de- 
generation which  is  well  marked.     The  spleen,  as  a  rule, 


CffOLERA.  117 

is  not  enlarged.     The  lungs  are  collapsed,  and  may  be  con- 
gested at  the  bases. 

In  patients  who  die  in  the  stage  of  reaction  the  tissues 
are  not  so  dry.  The  inflammatory  changes  in  the  lungs, 
stomach,  and  intestines,  and  the  degeneration  of  the  liver 
and  kidneys,  are  more  evident. 

Incubation  is  usually  between  two  and  three  days. 

Symptoms. — The  disease  is  usually  described  as  occur- 
ring in  the  following  five  stages,  although  any  of  these 
stages  may  be  omitted:  i.  Stage  of  preliminary  diarrhoea; 
2.  Stage  of  purging;  3.  Stage  of  collapse;  4.  Stage  of 
warmth;  and  5.  Stage  of  reaction. 

1.  Stage  of  Preliininary  Diarrhcea. — There  is  a  diarrhoea 
with  copious  stools,  attended  with  prostration  and  usually 
with  nausea  and  vomiting.  The  stools  are  as  dangerous  in 
spreading  the  disease  as  those  of  the  later  stages.  It  is  im- 
portant to  recognize  these  cases  early,  as  they  are  frequently 
amenable  to  treatment  if  it  be  not  too  long  delayed.  This 
diarrhoea  may  continue  for  from  one  to  five  days,  and  may 
either  end  in  recovery  or  may  pass  into  the  second  stage. 

2.  Stage  of  Purging. — With  or  without  this  stage  of  pre- 
liminary diarrhoea  the  second  stage  begins  abruptly,  usually 
at  night.  The  first  symptom  is  copious  purging,  first  of 
fecal  passages,  then  of  a  frothy  serous  fluid  without  odor, 
containing  whitish  flakes  of  desquamated  intestinal  epithe- 
lium, to  which  appearance  the  name  "  rice-water  "  is  applied. 
In  some  cases  the  discharges  may  be  stained  by  blood. 
They  may  be  accompanied  by  pain  and  griping,  but  usually 
their  passage  is  painless,  the  fluid  being  voided  in  gushes  or 
in  an  almost  continuous  stream. 

In  rapidly  fatal  cases  the  patient  may  die  before  any  purg- 
ing occurs.  To  these  cases  the  term  "  cholera  sicca  "  has 
been  applied.  Post-mortem  examination  shows  the  intes- 
tines to  be  full  of  the  discharge,  which  has  not  been  voided 
by  reason  of  paralysis  of  the  intestinal  wall. 

Vomiting  regularly  follows  the  onset  of  purging,  the 
vomited  matters  consisting  of  the  stomach-contents,  and 
later  of  the  "  rice-water  "  fluid.  There  are  rapidh'-developed 
symptoms  due  to  the  loss  of  water  from  the  system.    There 


IlS        J/.-iXr.lL    OF   rilE   PRACTICE    OF  MEDICIXE. 

is  rapid  emaciation ;  the  skin  is  loose  and  wrinkled ;  the 
eyes  are  sunken  ;  the  tongue  is  dr)^  The  urine  is  dimin- 
ished, and  contains  urea  in  excess,  albumin,  and  casts  ;  it 
may  be  suppressed.  There  is  distressing  thirst,  but  whatever 
drink  is  taken  is  immediately  rejected  by  the  stomach. 
There  are  in  the  abdomen  and  legs  muscular  cramps  which 
are  often  agonizing.  The  pulse  becomes  rapid  and  feeble; 
respirations  are  shallow  and  sighing.  The  skin  is  cold  and 
clammy,  but  the  internal  temperature  is  elevated.  The  mind 
is  anxious  and  distressed,  but  is  unclouded.  This  stage 
lasts  for  from  two  to  sixteen  hours,  and  from  it  the  patients 
may  recover  or  may  pass  into  the  third  stage. 

3.  Stage  of  Collapse,  or  Algid  Stage,  or  Cholera  Asphyxia. 
— The  vomiting  and  purging  continue  but  become  less  pro- 
fuse, and  may  finally  cease.  The  symptoms  of  collapse  and 
heart  failure  increase  rapidly.  The  skin  is  cold  and 
shrunken  and  of  a  leaden  hue ;  the  pulse  is  more  rapid  and 
thready,  becoming  finally  imperceptible.  The  external 
temperature  is  low;  the  internal  temperature  is  somewhat 
elevated.  This  stage  lasts  for  several  hours  or  it  ma\'  be 
protracted  for  a  day  or  so,  and  it  is  apt  to  be  fatal,  although 
patients  may  pass  into  the  warm  stage,  and  die  in  that,  or 
into  the  stage  of  reaction,  and  recover. 

4.  Warm  or  Tepid  Stage. — This  stage  is  sometimes  ob- 
served following  the  stage  of  collapse  in  patients  about  to 
die.  The  internal  temperature  rises ;  the  skin  becomes 
warm  and  of  a  more  natural  color.  The  purging  and  vomit- 
ing cease.  The  radial  pulse  can  again  be  felt.  The  patient, 
however,  becomes  comatose,  the  urine  is  suppressed,  and 
complicating  inflammations  of  the  pia  mater,  lungs,  stomach, 
or  intestines,  or  multiple  abscesses,  may  develop.  This 
stage  is  almost  certainly  fatal. 

5.  Stage  of  Reaction. — The  patient  may  pass  into  this 
from  any  stage  of  the  disease,  though  but  rarely  from  the 
stage  of  warmth.  The  symptoms  rapidly  disappear,  and 
convalescence  becomes  established  unless  interrupted  by 
complications.  There  may  be  seen  a  mottling  of  the  skin 
or  an  erythematous  rash. 

Complications  and  Sequelae. — There  is  frequently  sup- 


CHOLERA.  119 

pression  of  urine  that  may  persist  during  the  stage  of  reac- 
tion. The  patient  becomes  delirious,  the  pulse  becomes 
rapid  and  feeble,  and  death  occurs  with  coma.  To  these 
cases  the  term  "  cholera  typhoid  "  has  been  applied.  The 
same  symptoms  may  be  produced  by  septic  absorption  by 
the  denuded  intestinal  surface. 

Convalescence  may  be  protracted  by  the  continuance  of 
gastro-enteritis,  shown  by  irritability  of  stomach,  pain,  and 
diarrhoea.  If  croupous  colitis  occurs,  it  is  apt  to  be  fatal. 
There  may  be  broncho-pneumonia  or  an  irregular  form  of 
lobar  pneumonia.  There  may  be  inflammation  of  any  of 
the  serous  membranes  in  the  long-continued  cases.  ,No 
symptoms,  as  a  rule,  result,  and  the  occurrence  of  the 
lesion  is  known  only  from  post-mortem  evidence.  There 
may  be  multiple  abscesses  or  furuncles,  frequently  involving 
the  parotid  glands.  There  may  be  a  continuance  of  the 
muscular  spasms. 

"  Cholerine  "  is  a  term  frequently  employed  by  French  and 
German  authors.  By  French  writers  it  is  applied  to  cases 
of  the  preliminary  diarrhoea,  by  German  writers  it  designates 
cases  of  cholera  running  a  mild  course  and  terminating  in 
recovery. 

The  prognosis  varies  from  20  to  80  per  cent,  according 
to  the  epidemic.  The  cases  with  preliminary  diarrhoea 
most  usually  recover,  especially  if  treated  early.  The  prog- 
nosis in  the  stage  of  collapse  is  bad ;  in  the  tepid  stage, 
almost  hopeless. 

Treatment. — Propliylaxis. — Entrance  of  imported  cases 
into  a  port  should  be  prevented  by  rigid  quarantine.  All 
merchandise  and  fomites  should  be  steamed  thoroughly. 
If  quarantine  and  the  disinfection  of  imported  articles  can 
be  enforced  thoroughly,  spread  of  the  disease  should  not 
occur. 

All  discharges  from  cholera  patients  should  be  disin- 
fected, and  all  contamination  of  drinking-water  scrupu- 
lously avoided.  Those  in  attendance  on  the  sick  should 
wash  the  hands  frequently  in  an  acid  disinfectant  solution. 

Health  inspectors  should  visit  the  poorer  parts  of  the  in- 
fected cities  to  stop  any  cases  of  diarrhoea  and  to  treat  all 


I20       MAA'i'AL    OF   THE   PRACTICE    OF  MEDICINE. 

digestive  disturbances  that  may  occur.  All  water  should 
be  boiled  before  use. 

Attempts  to  procure  imnuinit)'  in  man  have  not  yet  been 
successful. 

Medicinal  Trcatvioit. — Cases  of  preliminary  diarrhoea 
should  be  treated  promptly  by  regulation  of  the  diet  and 
by  the  use  of  astringents  combined  with  opium.  As  the 
bacillus  is  killed  by  acids,  any  of  the  mineral  acids  may  be 
given;  salol  also  is  recommended.  The  patient  should 
be  kept  quiet  and  cool.  When  the  disease  has  once  devel- 
oped, treatment  is  directed  toward  mitigating  the  symptoms 
and  preventing  collapse.  Warm  applications  and  turpen- 
tine stupes  to  the  abdomen  and  extremities,  and  hot  baths, 
are  frequently  grateful. 

The  vomiting  and  purging  are  best  treated  by  hypo- 
dermic injections  of  morphine,  large  doses  being  usually 
borne  well.  Calomel  in  a  single  dose  of  20  grains  placed 
dry  on  the  tongue  has  at  times  been  useful. 

The  thirst  may  be  relieved  by  cracked  ice,  champagne,  or 
acidulated  water. 

Mineral  acids  and  intestinal  disinfectants,  such  as  salol, 
salicylate  of  bismuth,  and  /?-naphthol,  should  theoretically 
be  of  service,  but  their  administration  is  difficult  because  of 
the  vomiting. 

To  combat  the  dryness  of  the  tissues  and  the  concentra- 
tion of  the  blood,  subcutaneous  or  intravenous  injections  of 
warm  sterilized  saline  solutions  should  be  employed,  and 
they  are  often  of  the  utmost  value.  Rectal  injections  may 
also  be  given  when  the  purging  is  subsiding.  Cantani 
recommends  during  the  disease  frequent  high  rectal  injec- 
tions of  the  following  solution,  with  the  hips  elevated : 

^.  Tannic  acid,  3ij ; 

Laudanum,  3ss ; 

Water,  Oij. 

The  treatment  by  copious  rectal  enemata  is  termed  "  enter- 
oclysis." 

Heart  failure  is  to  be  treated  by  hot  applications  and  by 
hypodermic  stimulation   by  ether,  strychnine,  digitalis,  or 


YEL  L  O IV  FE  VER.  .  121 

whiskey.      Inhalations  of  ammonia,  amyl   nitrite,  or    pure 
oxygen  may  be  employed. 

During  convalescence  diuretics  may  be  indicated.  The 
diet  should  be  regulated,  and  residual  gastro-intestinal  symp- 
toms should  be  treated  as  they  may  arise. 

YELLOW    FEVER. 

Definition. — Yellow  fever  is  an  acute  infectious  disease; 
endemic  in  certain  warm  climates,  and  characterized  by 
fever,  jaundice,  and  a  tendency  to  hemorrhages. 

Etiology. — The  disease  is  endemic  in  certain  localities, 
principally  in  the  West  Indian  Islands,  parts  of  the  coast 
of  the  Gulf  of  Mexico,  and  the  west  coast  of  Africa.  It 
is  unknown  in  Europe.  From  time  to  time  it  makes  epi- 
demic excursions  into  warm  surrounding  countries,  and 
especially  into  the  Southern  United  States.  It  may  pene- 
trate into  more  northern  cities  to  a  slight  degree  in  the  sum- 
mer months.  The  epidemics  are  favored  by  poor  hygiene 
and  the  crowding  together  of  people  and  by  a  temperature  of 
over  70°  F.  Lower  temperatures  diminish,  and  frost  stops, 
the  epidemic.  Epidemics  are  more  common  on  the  sea- 
coast  and  in  low  altitudes,  an  elevation  of  one  thousand 
feet  procuring  nearly  absolute  safety.  The  spread  of  the 
disease  is  often  checked  by  houses,  walls,  or  streams. 

Immunity  may  be  secured  by  a  previous  attack  or  by 
long  residence  in  an  endemic  locality.  Native  races,  for  the 
latter  reason,  are  less  liable  to  the  disease,  and  when  they 
are  attacked  the  disease  in  them  runs  a  mild  course. 

Yellow  fever  is  not  contagious  by  contact  with  either  the 
living  or  the  dead  body,  but  the  germ  is  cast  off,  in  some  un- 
known way,  in  an  immature  state,  and  requires  further  devel- 
opment, after  which  infection  can  occur  through  the  medium 
of  the  air  or  by  fomites.  The  disease  is  introduced  into 
cities  chiefly  by  freight  and  merchandise,  and  quarantine 
and  disinfection  are  successful  if  thoroughly  performed. 

The  specific  germ  has  not  yet  been  determined  defi- 
nitely. 

Patholog-y. — The    tissues   of  the   body  are   usually  in- 


122        M.IXCAL    OF   THE   PRACTICE    OF  MEDICINE. 

tensely  jaundiced.  There  may  be  subcutaneous  hemor- 
rhages. The  heart-muscle  is  pale  and  degenerated.  The 
liver  shows  advanced  fatty  degeneration  of  its  cells  and  is 
of  a  "  cafe  au  lait  "  color.  The  spleen  is  not  enlarged.  The 
kidneys  show  the  lesions  of  either  acute  diffuse  inflamma- 
tion or  a  severe  form  of  parenchymatous  degeneration.  The 
mucous  membrane  of  the  stomach  is  swollen  and  shows 
traces  of  a  catarrhal  inflammation,  and  there  is  frequently 
found  in  the  stomach  the  "  black  vomit,"  which  consists  of 
mucus  and  altered  blood. 

Incubation  varies  from  one  to  twenty-five  days,  the  aver- 
age duration  being  seven  days  ;  it  is  less  than  this  in  severe 
cases. 

Symptoms. — The  disease  consists  in  severe  cases  of  three 
stages:  (i)  stage  of  invasion;  (2)  stage  of  remission  or 
"  stage  of  calm ;"  (3)  stage  of  relapse. 

Stage  of  Invasion. — The  onset  is  sudden  and  is  initiated 
by  a  chill,  or  by  convulsions  in  the  case  of  children.  The 
temperature  rises  rapidly  to  103°  F.  in  very  mild  cases,  to 
105°  or  106°  F.  in  the  severer  forms,  and  it  may  be  even 
higher.  The  pulse  is  usually  full  and  ranges  from  Soto  120, 
being  usually  less  than  would  be  expected  from  the  height  of 
the  fever.  In  some  cases  the  pulse  is  slowed  from  the  first 
(50  to  60).  Headache  and  pains  in  the  back  and  in  the 
bones  are  decided  and  severe ;  the  face  is  flushed  ;  the  eyes 
are  suffused  and  watery.  The  stomach  is  irritable ;  sharp 
attacks  of  vomiting  occur  frequently,  and  may  be  of  the 
projectile  type.  There  may  be  vomiting  of  blood.  The 
bowels  are  constipated.  There  are  restlessness  and  possibly 
delirium  or  active  mania.  The  urine  is  diminished  and 
contains  albumin  and  casts. 

While  this  is  the  usual  course,  mild  cases  are  frequently 
seen.  The  patient  may  be  walking  about  with  a  little  fever 
(101°  to  102°  F.),  headache,  lassitude,  and  occasionally 
vomiting.  The  first  stage  usually  lasts  for  three  days, 
though  it  may  terminate  in  from  one  to  six  days. 

The  second  s/age,  or  the  stage  of  calm,  is  marked  by  a  fall 
of  temperature,  frequently  to  subnormal,  and  by  disappear- 
ance of  the  other  symptoms.     In  mild  cases  convalescence 


YELLOW  FLJIVKK.  I  23 

begins  at  this  time.  In  these  cases,  as  there  is  no  jaundice, 
the  term  "yellow"  fever  is  evidently  a  misnomer.  In  some 
patients  who  recover,  however,  slight  jaundice  may  appear 
on  the  fifth  day.  In  severer  cases,  after  the  stage  of  calm 
has  lasted  for  iwo  days  the  patient  develops  the  symptoms 
of  the  third  stage. 

The  tJiird  stage  is  marked  by  jaundice,  by  a  tendency  to 
hemorrhages,  and  usually  by  uraemic  symptoms.  The 
temperature  rises,  and  the  symptoms  become  aggravated. 
The  pulse  is  gaseous  and  may  be  abnormally  slow,  falling 
sometimes  to  40  beats  in  the  minute.  Jaundice  now  appears, 
of  haematogenous  origin,  and  is  most  pronounced.  Vomiting 
begins  anew,  and  in  a  considerable  number  of  cases  the  so- 
called  "black  vomit"  occurs.  This  is  not  always  vomited,  but 
may  be  retained  in  the  stomach.  There  are  usually  hemor- 
rhages under  the  skin,  forming  large  ecchymoses,  and  from 
any  of  the  mucous  membranes.  Cerebral  symptoms  are 
usually  present.  The  patient  may  become  dull  and  stupid, 
or  there  may  be  delirium,  frequently  of  the  maniacal  type. 
Fatal  cases  usually  pass  into  coma.  The  urine,  which  is 
greatly  diminished,  contains  large  amounts  of  albumin  and 
casts,  and  may  contain  blood ;  in  severer  cases  it  is  alto- 
gether suppressed. 

In  this  stage  the  majority  of  patients  die,  from  collapse, 
from  the  hemorrhages,  or  in  a  "  typhoid  "  condition.  In 
some  cases  death  is  due  to  uraemia.  Fatal  cases  usually  die 
between  the  fifth  and  the  seventh  day  of  the  disease. 

Complications  and  sequelae  are  infrequent.  There  may 
be  parotiditis,  furunculosis,  gastritis,  or  diarrhoea. 

Diagnosis. — The  disease  is  chiefly  to  be  diagnosed  from 
malarial  fever  with  complicating  jaundice.  These  cases  also 
frequently  show  a  tendency  to  hemorrhage,  and  occur  in  the 
same  locality  and  at  the  same  time  at  which  yellow  fever  is 
apt  to  appear.  The  presence  of  the  malarial  organism  and 
the  results  of  quinine  treatment  clear  the  diagnosis  in  doubt- 
ful cases. 

The  prognosis  depends  upon  the  nature  of  the  epidemic, 
varying  from  10  to  85  per  cent.  It  is  better  in  private  prac- 
tice and  among  the  native  races  and  in  young,  temperate 


124        J/.t.Vr.lL    OF   THE   PRACTICE    OF  MEDICLXE. 

individuals.  Cerebral  symptoms,  hemorrhages,  suppression 
of  urine,  and  pronounced  jaundice  mark  the  bad  cases. 

Treatment. — Prophylaxis. — There  should  be  rigorous  dis- 
infection of  all  ships,  merchandise,  and  mails  arriving  from 
infected  localities.  Patients  should  be  quarantined  abso- 
lutely, and  their  clothing  and  bedding  be  disinfected.  In 
infected  localities  persons  who  arc  not  necessary  for  the  care 
of  the  sick  should  not  remain. 

The  patient  should  be  nursed  carefully  in  a  wcU-vcntilated 
room,  and  symptoms  should  be  treated  as  they  arise. 

Diaphoresis  in  the  first  stage  often  affords  relief,  while  the 
headache  and  pains  are  best  controlled  by  phenacetine,  salol, 
opium,  or  single  large  doses  of  quinine. 

The  fever,  if  high,  may  be  reduced  by  cold  baths,  spong- 
ing, the  cold  pack,  or  internal  antipyretics. 

Vomiting  is  controlled  by  sinapisms,  dilute  hydrocyanic 
acid,  oxalate  of  cerium,  cocaine  in  gr.  \  doses,  cracked  ice, 
bismuth,  or  by  rest  and  by  hypodermatics  of  morphine. 

Internal  styptics  have  but  little  control  over  the  hemor- 
rhages. 

Suppression  of  urine  is  to  be  treated  by  cups  and  poultices 
applied  to  the  kidneys,  diuretics,  rectal  injections  of  warm  salt 
water,  or  the  hot  steam  bath.  Sternberg  recommends  small 
doses  of  bichloride  of  mercury  with  bicarbonate  of  soda. 

The  action  of  the  heart  is  to  be  sustained  by  stimulants 
given  in  sufficient  doses  to  avert  danger  from  collapse, 

SYPHILIS. 

Syphilis  occurs  in  all  civilized  countries,  and  all  races  are 
susceptible.  Among  aboriginal  races  it  becomes  a  formid- 
able disease,  but  modern  methods  of  treatment  have  greatly 
reduced  its  virulence.  It  is  said  to  have  been  inoculated 
in  monkeys  and  apes,  but  it  is  doubtful  if  it  exists  in  other 
lower  animals.     Synonym  :  The  pox. 

Lustgarten  in  1844  described  a  bacillus  somewhat  shorter 
than  the  tubercle  bacillus,  not  occurring  free,  but  in  the  cells, 
and  found  in  the  secretions  of  syphilitic  sores  and  in  some 
gummata  and  condylomata.  It  is  almost  identical  in  appear- 
ance with  the  smegma  bacillus.     The  causative  relation  of 


SYriiii.is.  125 

this  bacillus  to  the  disease  has  not  yet  been  absolutely- 
proven.  Syphilis  may  occur  as  an  acquired  and  as  a 
hereditary  disease. 

Acquired  Syphilis. 

Acquired  syphilis,  which  is  the  most  usual  form,  is  due  to 
inoculation  by  the  discharges  from  the  earlier  lesions  of  the 
disease.  Ordinarily  it  results  from  sexual  intercourse,  through 
minute  abrasions  of  the  genitalia.  "  Extra-genital  syphilis  " 
may  be  caused  by  infected  throat  or  dental  instruments, 
razors,  pipes,  cigars,  cups,  eating  utensils,  and  by  kissing  or 
by  beastly  practices.  It  may  be  caused  by  infected  human- 
ized virus  in  vaccination,  or  by  wet-nurses.  It  is  not  trans- 
mitted through  normal  secretions.  Once  acquired,  it  is  rare 
that  the  disease  can  be  reinoculated  successfully. 

Periods  of  the  Disease. — Three  periods  are  described : 
(i)  A  primary  stage,  from  the  moment  of  infection  until 
the  outbreak  of  constitutional  symptoms,  lasting  for  eight 
to  ten  weeks.  There  are  two  sub-periods  to  this  stage  :  {a) 
first  incubation  period  of  from  fourteen  to  twenty-one  days, 
terminating  with  the  appearance  of  the  primary  sore  ;  {b) 
second  incubation  period,  lasting  from  the  appearance  of 
the  primary  sore  until  the  outbreak  of  the  constitutional 
symptoms.  (2)  A  secondary  stage,  comprising  the  fever, 
exanthemata,  and  their  complications,  lasting  from  one  to 
three  years.  (3)  A  tertiary  stage,  consisting  of  gummata, 
visceral  syphilis,  and  sequelae. 

Symptoms  of  the  Primary  Stage. — The  first  incubation 
period  lasts  for  from  fourteen  to  twenty-one  days  after  infec- 
tion, without  symptoms. 

The  second  incubation  period  is  initiated  by  the  develop- 
ment of  the  chancre  ("  hard,"  "  indurated,"  or  "  Hunterian" 
chancre),  which  begins  as  a  red  papule  on  an  indurated  base, 
grows  for  from  two  to  four  weeks,  and  then  slowly  ulcerates 
in  the  centre;  or  it  may  begin  as  an  indurated,  indolent  sore. 
Suppuration  and  gangrene  may  occur  as  secondary  processes 
in  weakly  and  alcoholic  subjects.  The  chancre  appears  as 
an  indurated  papule  on  the  preputial  sulcus,  in  the  orifice 
of  the  urethra,   on  the  edge  of  the  labia,   or  on  the  lips. 


126        J/.I.VC:-I/.    OF   THE   PA'.ICT/CE    OF  MEDICIXE. 

The  induration  is  broad  and  shallow  ("parchment  indura- 
tion ")  upon  the  gjlans  penis  and  on  the  inner  surface  of  the 
labia.     There  is  but  one  chancre,  with  but  rare  exceptions. 

Care  should  be  taken  not  to  mistake  the  inflammatory- 
induration  following  caustic  applications  to  chancroids  or 
herpes  for  that  of  a  true  chancre,  and  the  possibility  of  a 
mixed  infection  of  chancre  and  chancroid  must  be  borne 
in  mind.  Microscopically  the  chancre  consists  of  a  cellular 
infiltration  with  acute  obliterating  endarteritis  of  the  neigh- 
boring arteries. 

Painless  swelling  of  the  neighboring  lymph-glands  occurs 
from  eight  to  fourteen  days  after  the  appearance  of  the 
chancre,  the  glands  all  over  the  body  becoming  affected, 
the  nearest  glands  being  enlarged  first.  Thus  in  genital 
syphilis  the  inguinal  glands  become  enlarged  in  the  third 
or  fourth  week  after  the  original  infection,  the  axillary  glands 
in  the  fifth  week,  and  the  cervical  glands  in  the  seventh 
week.  The  lymphatics  entering  the  glands  may  be  felt 
often  as  indurated  cords.  Suppuration  does  not  occur 
unless  from  some  secondary  pus  infection. 

Symptoms  of  the  Secondary  Stage. — There  may  be  fever 
ushering  in  the  second  stage,  or  the  fever  may  appear  late  in 
the  disease.  The  temperature  may  be  loi  °  to  103°  F.,  or  even 
104°  to  105°  F.  It  is  marked  by  remissions,  and,  as  a  rule, 
persists  for  but  a  few  days.  Exceptionally  the  fever  may 
last  for  weeks  or  months,  and  a  diagnosis  from  malarial  fever 
may  be  difficult.  In  one  case  observed  by  the  writer  the 
fever  lasted  for  over  four  months,  notwithstanding  energetic 
antisyphilitic  treatment.  The  spleen  in  prolonged  fever  cases 
is  enlarged.  Pharyngitis  with  a  sharp  line  of  demarcation 
on  the  soft  palate,  and  tonsillitis  with  superficial  symmetrical 
ulceration,  are  often  noted,  usually  at  the  time  of  fever,  and 
headache,  lassitude,  and  pains  in  the  back  and  in  the  limbs 
are  complained  of 

A  macular  eruption  usually  manifests  itself  as  the  first 
eruption.  It  appears  on  the  abdomen  during  the  eighth 
week  after  infection  ;  on  the  chest  during  the  ninth  week; 
on  the  shoulders  during  the  tenth  week;  on  the  arms 
durinsf   the    eleventh    week;    on    the  forearms    durine    the 


SYPJI/L/S.  127 

twelfth  week  ;  and  on  the  hands  durinf^  tlie  thirteenth  week. 
This  eruption  is  symmetrical,  follows  the  cleft-lines  of 
the. skin,  and  is  of  a  dull  coppery  color.  Papules  occur 
somewhat  later,  being  rarely  seen  before  the  third  month 
after  infection.  They  may  be  small  or  large,  occurring 
in  a  row  below  the  line  of  the  hair  on  the  forehead ;  they 
constitute  the  corona  Venerea.  Pustules  may  occur  as  a 
late  exanthem  rarely  before  the  fourth  month.  The  pus- 
tules may  be  small  and  shotty,  closely  resembling  variola, 
or  they  may  be  large  like  impetigo,  or  they  may  be  changed 
into  deep  ulcerations  covered  by  rupial  crusts. 

A  squamous  form  of  eruption  is  described,  not  unlike 
psoriasis,  but  less  scaly.  This  form  usually  is  seen  on  the 
palms  of  the  hands  and  the  soles  of  the  feet. 

If  papules  occur  in  regions  where  the  skin  is  moist,  as 
about  the  anus  and  vulva,  they  become  sodden,  devoid  of 
epidermis,  and  show  white  points  upon  their  surface.  These 
papules  are  the  "  flat  condylomata." 

The  eruptions  appearing  in  mucous  membranes  undergo 
maceration  and  are  known  as  mucous  patches,  warts,  and 
condylomata. 

Mucous  patches  are  rounded,  slightly  raised,  and  covered 
with  a  grayish  film.  Their  discharge  is  exceedingly  virulent. 
They  are  usually  seen  on  the  inner  side  of  the  cheek,  oppo- 
site the  second  molar  tooth,  on  the  under  surface  of  the 
tongue,  and  at  the  angles  of  the  mouth.  They  are  really 
macerated  syphilitic  papules.  If  the  papillae  in  the  papule 
hypertrophy,  they  constitute  the  condyloma  or  wart,  accord- 
ing to  whether  or  not  the  papules  are  fused. 

For  a  detailed  description  of  syphilitic  eruptions  the 
reader  is  referred  to  special  works  on  dermatology. 

There  may  be  extensive  thinning  of  the  hair.  Iritis  may 
develop  in  from  three  to  six  months  after  the  chancre,  and 
may  be  serious.  Anaemia  and  cachexia  may  be  marked  dur- 
ing the  secondary  stage,  which  lasts  for  from  one  to  three  years. 

Symptoms  of  the  Tertiary  Stage. — This  stage  is  marked 
by  late  syphilides,  gummata,  amyloid  degeneration,  sclerosis, 
and  visceral  disease. 

Late  syphilides  are  unsymmetrical  and  have  a  tendency 


128      j/.ixr.i/.  OF  THE  pkaci-ice  of  medicixe. 

to  deep  ulceration,  leaving  cicatrices.  The  rupial  stratified 
crusts  cover  round  deep  ulcers.  Periosteal  nodes  along  the 
course  of  the  tibiae  are  commonly  observed.  Syphilitic 
periostitis  is  marked  by  severe  pain,  worse  at  night — the  so- 
called  "  osteocopic  pain."  Tubercular  and  unsymmetrical 
serpiginous  eruptions  characterize  the  tertiary  period. 

GuDiuiata  may  develop  in  the  skin,  the  subcutaneous 
tissues,  the  muscles,  or  the  internal  organs.  They  may  be 
distinctly  circumscribed,  or  they  may  occur  as  a  diffused 
infiltration.  The  nodule  or  gumma  consists  of  small  cells 
with  a  gelatinous  basement  substance.  It  may  remain  un- 
changed, may  become  absorbed,  may  undergo  cheesy  degen- 
eration can  be  invested  with  a  fibrous  capsule,  may  be  con- 
verted to  fibrous  tissue,  or  may  suppurate.  Gummata  of  the 
skin,  of  the  mucous  membranes,  of  the  bones,  and  of  the 
cartilages  undergo  ulceration  and  extensive  sloughing.  In 
this  way  the  cartilages  of  the  nose  may  disappear,  or  there 
may  be  an  ozaena  with  necrosed  bone  in  the  nose,  or  the 
palate  or  the  tonsils  may  be  totally  ulcerated.  Cicatrices  of 
the  mucous  membranes  may  result  in  stricture. 

In  the  viscera  gummata  frequently  undergo  fibroid  trans- 
formation with  puckering  and  deformity. 

Amyloid  degenei-ation  frequently  follows  tertiary  syphilis, 
and  degeneration-changes  of  a  sclerotic  nature  are  com- 
monly observed,  as  in  locomotor  ataxia  and  arterio-sclerosis. 

The  internal  forms  of  syphilis  will  be  treated  of  in  detail 
under  the  titles  of  the  diseases  of  the  various  organs. 

It  is  important  to  remember  that  the  division  into  the 
three  stages  is  not  always  sharply  drawn  in  actual  experi- 
ence, symptoms  of  one  stage  overlapping  and  encroaching 
upon  those  of  the  preceding  or  the  following  period ;  it 
should  be  borne  in  mind  also  that  by  systematic  judicious 
treatment  the  course  of  the  disease  can  be  modified  materi- 
ally. There  are  also  light  cases  in  which  tertiary  and  even 
secondary  symptoms  may  not  develop,  especially  if  the  case 
be  treated  from  the  start. 

The  disease  is  not  considered  inoculable  after  the  third 
year. 

The   prognosis   is    generally    good.      Visceral   syphilis, 


syrn/L/s.  129 

especially  of  the  brain  and  its  membranes,  may  terminate 
fatally,  or  death  may  indirectly  result  by  arterio-sclerosis, 
aneurysm,  or  locomotor  ataxia. 

Treatment. — Prophylactic. — Syphilitic  patients  should  not 
marry  until  three  years  have  elapsed  since  the  infection.  It 
is  even  better  to  extend  this  period  to  five  years.  Personal 
prophylaxis  consists  in  personal  purity.  Governmental  reg- 
ulation of  prostitution  hardly  lessens  the  dangers.  Surgical 
and  dental  instruments  should  be  sterilized  scrupulously, 
and  it  is  better  for  the  surgeon  to  have  two  sets  of  instru- 
ments, one  set  being  used  exclusively  for  syphilitic  patients. 
Surgeons  should  handle  syphilitic  lesions  with  care,  espe- 
cially if  there  be  abrasions  on  the  fingers,  and  after  such 
handling  should  cleanse  their  hands  in  strong  antiseptic 
solutions.  Syphilitic  patients  with  mucous  patches  should 
have  their  own  drinking  and  eating  utensils  and  their  own 
towels,  and  should  be  prohibited  from  kissing.  A  syphilitic 
husband  should  live  apart  from  his  wife  for  at  least  two 
years. 

Curative. — {a)  Treatment  of  the  Primary  Stage. — It  is  of 
no  use  to  excise  the  chancre.  No  regular  treatment  should 
be  initiated  until  the  macular  eruption  appears,  making  the 
diagnosis  positive.  Should  sloughing  or  suppuration  occur, 
it  should  be  treated  on  general  principles. 

ip)  Treatment  of  the  Secondary  Stage. — The  specific  drug 
is  mercury.  Its  use  should  be  begun  upon  the  first  appear- 
ance of  the  macular  eruption,  and  be  continued  for  at  least 
two  years — for  the  first  year  alone,  and  for  the  second  year 
combined  with  iodide  of  potassium. 

There  are  two  ways  of  giving  mercury :  One  way  is  to 
give  it  intermittently,  whenever  symptoms  appear,  ceasing 
its  use  in  quiescent  periods ;  the  other  way  is  to  give  it 
steadily  in  small  tonic  doses.  The  latter  plan  seems  pre- 
ferable. 

Mercury  may  be  given  in  the  following  ways :  Gray 
powder,  or  hydrargyrum  cum  creta,  gr.  j,  with  gr.  j  of 
Dover's  powder,  in  pill,  four  to  six  times  a  day ;  tab- 
lets of  the  biniodide,  gr.  y^g,  three  times  a  day ;  tablets 
of  the    protiodide,    gr.    \,    three  times  a  day.     Inunctions 


130        M.IA'CIL    OF   THE   PRACTICE    OF  MEDICINE. 

o\  mercurial  ointment  may  be  used.  One  dram  suffices 
for  a  single  inunction,  and  one  application  a  day  suf- 
fices. The  ointment  should  be  rubbed  on  successive 
nights  into  the  lateral  aspects  of  the  thorax  and  the  arm 
on  one  and  then  on  the  other  side,  then  on  the  sides  of  the 
abdomen,  then  on  the  inner  side  of  either  thigh.  This 
gives  six  localities  for  application.  At  the  end  of  six  days 
the  patient  should  take  a  hot  bath,  and  then  the  circuit  is 
again  gone  over.  Mercurial  inunctions  are  recommended 
when  an  immediate  effect  is  desired. 

Subcutaneous  injections  of  mercury  have  been  recom- 
mended warmly.  With  a  sterilized  needle  the  bichloride 
(gr.  \  in  Tllxx  of  water)  or  calomel  (gr.  j-ij  in  ITlxx  of 
glycerin  or  of  olive  oil)  may  be  injected  once  a  week  into 
the  gluteal  region.  Such  injections,  however,  are  apt  to 
be  painful. 

Fumigations  of  calomel  may  be  employed,  the  patient 
sitting  in  a  chair  wrapped  in  a  blanket.  Under  the  chair  is 
to  be  placed  an  alcohol  lamp  over  which  is  a  strip  of  tin 
properly  supported  in  place,  20  grains  of  calomel  being  piled 
in  a  heap  at  the  point  where  the  flame  touches  the  tin 
(Fig.  i).  The  patient  goes  to  bed  after  the  fumigation, 
still  wrapped  in  the  blanket. 

During  the  mercurial  treatment  care  should  be  taken  not 
to  push  the  drug  to  the  point  of  salivation.  Before  the 
treatment  the  teeth  should  be  put  in  order  and  the  tartar  be 
removed.  During  the  treatment  the  teeth  should  be 
brushed  twice  a  day,  and  gargles  of  a  saturated  solution  of 
chlorate  of  potassium  be  ordered.  Green  vegetables  and 
fruit  should  be  avoided.  Upon  the  first  appearance  of  sali- 
vation the  drug  should  be  stopped  for  the  time.  Should 
diarrhoea  follow  the  internal  use  of  mercurials,  small  doses 
of  Dover's  powder  or  of  opium  should  be  given  in  com- 
bination. Anaemic  conditions  call  for  the  simultaneous 
administration  of  iron,  and  proper  hygiene  must  be  en- 
forced in  every  instance. 

At  the  close  of  one  year  there  seems  to  be  an  advantage 
in  combining  potassium  iodide  with  the  mercury  ("  mixed 
treatment "),  as  in  the  following  prescriptions : 


SYPHILIS.  131 

1^.  Hydrarg.  bichloridi,  gr.  j ; 

Potassii  iodidi,  ,5v; 

Aquae, 

Syr.  sarsaparillae  comp.,  aa  .^ij. — M. 

Sig.  A  teaspoonful,  largely  diluted,  after  each  meal. 

I^.   Hydrarg.  bichloridi,  gr.  ij ; 

Potassii  iodidi,  5J  ; 

Tinct.  cinchon.  comp.,  oiijss  ; 

Aquae,  oSS. — M. 

Sig.    A  teaspoonful  in  water  after  each  meal. 

ic)  Treatment  of  the  Tertiary  Stage. — The  drug  par  excel- 
lence is  iodide  of  potassium,  which  has  a  specific  action. 
The  initial  dose  is  from  10  to  30  grains  three  times  a  day, 
largely  diluted  in  water  or  in  milk.  In  certain  cases  the 
drug  should  be  pushed  to  greater  limits,  from  3  to  4  drams 
being  required  for  a  single  dose.  This  is  especially  the 
case  in  cerebral  syphilis. 

Hereditary  Syphilis. 

The  hereditary  differs  from  the  acquired  form  of  syphilis 
chiefly  in  the  absence  of  the  primary  stage. 

Etiology. — FatJier  Syphilitic. — (a)  The  child  may  be 
infected  directly  (sperm  inheritance).  The  nearer  the  pro- 
creation is  to  the  primary  lesion  in  the  father,  the  greater 
are  the  chances  of  the  child  being  infected.  The  power  of 
transmission  rarely  exceeds  three  or  four  years.  It  is 
possible,  however,  for  a  syphilitic  father  to  beget  a  healthy 
'child.  {b)  The  mother  may  be  infected  through  the 
placental  circulation,  but,  whether  or  not  active  syphilis 
appears,  a  syphilitic  child  cannot  infect  the  mother  after 
birth,  a  maternal  immunity  having  been  created.  This  is 
known  as  Colles'  law. 

Mother  Syphilitic. — If  the  mother  be  in  the  active  stages 
at  the  time  of  conception,  the  embryo  is  usually  infected. 
If  the  disease  be  acquired  a  few  months  prior  to  labor,  the 
child  usually  escapes.  Infection  of  the  child  may  be  min- 
imized by  judicious  antisyphilitic  treatment  of  the  mother 


1^2        M.lXr.lL    OF   THE   FKACT/CE    OF  MEDICINE. 

during  pregnancy.  About  one-third  of  mothers  abort,  and 
gummatous  placenta  or  degeneration  of  the  placental  folli- 
cles may  be  found. 

BotJi  Pixrcnts  Syphilitic. — The  infant  mortality  from  pater- 
nal transmission  is  28  per  cent. ;  from  maternal  transmission 
60  per  cent. ;  from  both  mother  and  father,  68  per  cent. 
Parents  with  tertiary  s\'philis  are  apt  to  beget  sickly 
children  with  a  tendency  to  neurotic  affections. 

Symptoms. — If  the  child  be  born  diseased,  there  is  evi- 
dent poor  development  and  malnutrition.  Bullas  (pemphi- 
gus neonatorum)  are  usually  seen  upon  the  hands  and  feet ; 
the  lips  are  fissured ;  the  child  snuffles ;  the  liver  and  spleen 
are  enlarged ;  and  the  epiphyses  are  apt  to  be  separated. 
Such  a  child  is  not  likely  to  survive. 

If  the  child  be  born  apparently  healthy,  symptoms  may 
not  develop  until  the  fourth  to  the  eighth  week.  Then  the 
child  snuffles  and  cutaneous  lesions  are  apt  to  appear, 
especially  about  the  nates.  There  are  usually  brownish- 
red  patches  with  a  well-defined  border,  or  they  may  be 
papular.  Indolent  boils  in  a  copper-colored  base  may 
develop.  Fissures  (rhagades)  are  apt  to  develop  about  the 
lips,  the  secretions  from  such  fissures  being  intensely  viru- 
lent. The  resulting  cicatrices  are  characteristic.  There 
may  be  falling  out  of  the  hair.  Syphilitic  onychia  may 
develop. 

General  glandular  enlargements  are  not  so  common  in  the 
hereditary  as  in  the  acquired  form  of  syphilis.  There  may 
be  purpura  ha^morrhagica  neonatorum,  associated  usually 
with  diseased  arteries.  The  child  is  apt  to  show  increasing 
malnutrition,  looking  like  a  wrinkled  old  man.  The  cry  is 
shrill  and  piercing.  Various  cutaneous  eruptions  may 
appear,  with  mucous  patches  or  with  ulcerations  of  mucous 
membranes.  The  nose  may  fall  in.  Developmental  lesions 
of  bones  may  develop.  There  may  be  thinning  of  the 
bones  of  the  skull  (craniotabes)  or  irregular  growth  of 
bone.  There  may  be  separation  or  suppuration  of  the 
epiphyseal  ends  of  bones,  or  formation  of  osteophytes  on 
the  long  bones.    There  may  be  gummata  of  internal  viscera. 

The    teeth    are    apt    to    be    deformed,    constituting    the 


ACUTE   MILIARY  TUBERCULOSIS.  I  33 

"  Hutchinson  teeth  "  (PI.  10,  Fig.  2).  The  upper  central 
incisors  of  the  permanent  set  are  usually  the  ones  most 
involved.  The  teeth  are  peg-shaped,  stunted,  and  at  the 
cutting  edge  there  is  a  notch  in  which  the  dentine  is  ex- 
posed. 

Interstitial  keratitis  is  apt  to  occur  about  puberty.  The 
cornea  has  a  ground-glass  appearance  which  may  disappear 
or  may  lead  to  permanent  opacity.  There  may  be  iritis. 
Deafness  from  labyrinthine  disease  may  develop.  The  patient 
has  a  generally  stunted  appearance — undersized,  and  appar- 
ently much  younger  than  he  really  is.  There  may  be 
nodosities  of  the  long  bones  from  gummatous  periostitis, 
or-  there  may  be  dactylitis.  For  a  detailed  account  of 
joint-  and  bone-lesions  the  reader  is  referred  to  works  on 
surgery. 

Treatment. — The  mother  should  receive  mixed  treat- 
ment throughout  pregnancy,  and  the  treatment  should  be 
continued  with  the  child.  The  treatment  of  the  child  is 
like  that  of  adults,  but  proportionately  smaller  doses  should 
be  given. 

The  syrup  of  Giberts  is  recommended : 

^.   Hydrarg.  biniodidi,  gr.  ss ; 

Potassii  iodidi,  Sij ; 

Syr.  zingiberis, 

Aq.  destillat.,  aa  oij- — M. 

Sig.    Dose,  gtt.  v-x  for  a  child  six  months  old. 

As  a  rule,  mercurials  have  less  effect  upon  the  gums  and 
more  effect  upon  the  bowels  in  children  than  in  adults. 

ACUTE  MILIARY  TUBERCULOSIS. 

Definition. — Acute  miliary  tuberculosis  is  an  acute 
tubercular  infection  characterized  by  an  eruption  of  miliary 
tubercles  in  various  parts  of  the  body,  with  fever,  symptoms 
of  local  infection,  and -a  fatal  ending. 

Etiology. — The  etiology  of  tubercular  disease  is  con- 
sidered in  detail  under  Tubercular  Disease  of  the  Lungs 
(p.  336).     Miliary  tuberculosis  is  a  general  infection  follow- 


134     ^v.-i.vr.-iL  OF  THE  practice  of  medfclxe. 

ing  some  local  tubercular  lesion,  and  is  due  to  the  escape 
of  tubercle  bacilli  into  the  blood,  where  they  find  lodgement 
in  \arious  organs  and  develop  tubercles. 

The  primary  tubercular  focus  may  be  apparent  or  may 
be  unsuspected.  It  may  be  local  tubercular  disease  of  the 
lung,  of  the  lymph-glands,  of  the  kidneys,  or  of  the  bones. 
Frequently  the  source  is  found  to  be  tubercular  bronchial 
glands,  which  may  even  rupture  into  a  pulmonar)'  vein  and 
shower  bacilli  into  the  circulation.  A  primary  tuberculosis 
of  the  thoracic  duct  has  been  demonstrated.  Well-marked 
cases  of  miliary  tuberculosis  have  followed  the  use  of 
Koch's  tuberculin  given  for  the  cure  of  a  local  tubercular 
inflammation. 

Patholog-y. — Tubercles  (for  the  detailed  structure  of 
which  see  Tubercular  Disease  of  the  Lungs)  are  found  in 
various  organs  of  the  body.  They  are  usually  the  size  of  a 
pin's  head,  but  they  may  appear  larger  from  a  number 
being  coalesced.  When  recent  they  are  translucent,  gray- 
ish, and  contain  bacilli.  In  older  cases  they  may  be 
caseous  and  yellow  in  the  centre  and  may  contain  no 
bacilli.  Tubercles  may  be  found  in  the  lungs,  pleura,  peri- 
toneum, liver,  kidne\-s,  lymph-glands,  pia  mater,  in  the 
bone-marrow,  and  in  the  choroid  coat  of  the  eye.  Less 
frequently  they  are  found  in  other  parts.  There  is  no 
regularity  about  their  distribution :  they  may  be  abundant 
in  some  organs  and  scanty  or  absent  in  others,  or  they  may 
be  more  generally  distributed.  This  lack  of  regularity 
gives  rise  to  great  variations  in  clinical  types.  With  the 
tubercles  are  often  found  associated  various  forms  of  in- 
flammatory products  or  ordinary  granulation-tissue. 

Symptoms  are  general  and  local. 

Goicral  symptoms  are  due  to  toxines  of  the  general  infec- 
tion. Fever  is  a  marked  feature  and  lasts  throughout  the 
disease.  Its  absence  is  rare.  It  may  be  intermittent  at  the 
onset,  resembling  malarial  fever.  At  the  height  of  the 
disease  it  is  usually  markedly  remittent,  though  it  may  be 
continuous.  An  "  inversive  type  "  has  been  described  in 
which  the  highest  temperature  occurs  in  the  morning — a 
peculiarity  rarely  seen  in  other  diseases. 


ACUTE   M/fJARY   TUBERCULOSIS.  1 35 

The  pulse  is  more  rapid  and  feeble  than  can  be  accounted 
for  by  the  fever,  running  between  I  lO  and  130. 

The  breathing  is  rapid,  sometimes  as  frequent  as  40  to  60 
to  the  minute,  and  it  is  characteristic  for  the  patient  not 
to  complain  of  shortness  of  the  breath. 

There  may  be  profuse  sweats.  These  may  occur  after 
remissions  of  temperature,  or  irregularly  as  an  evidence  of 
sepsis. 

The  mental  condition  is  usually  cheerful,  and  the  mind  is 
bright  even  in  long-continued  cases ;  the  patient  complains 
only  of"  having  fever  and  a  little  cold."  This  sign  is  highly 
characteristic,  and  is  often  a  good  point  of  diagnosis  from 
typhoid  fever. 

In  acute  cases  with  meningitis  there  may  be  delirium 
which  is  either  mild  or  severe  and  amounting  to  mania. 
Stupor  or  coma  succeeds  the  delirium. 

The  spleen  is  usually  large;  the  urine  is  that  of  fever,  or 
it  may  contain  albumin. 

The  close  of  the  disease  is  characterized  by  the  symptoms 
of  the  typhoid  state. 

Local  syinptoiiis  depend  upon  the  locality  and  extent  of 
the  tubercular  deposits  in  the  various  viscera.  While  many 
organs  are  invaded,  some  are  more  apt  to  give  symptoms 
than  others,  and  the  organ  most  invaded  will  give  a  leading 
character  to  the  local  symptoms. 

If  the  meninges  are  involved,  the  local  symptoms  will  be 
those  of  meningitis.  It  is  important  to  remember  that  in 
children  tubercular  meningitis  is  acute  miliary  tuberculosis 
with  symptoms  of  meningitis,  while  in  adults  it  is  possible 
for  it  to  be  a  local  lesion  without  involvement  of  other  organs. 

Involvement  of  the  pleura  gives  rise  to  pleurisy.  A 
double  pleurisy  with  effusion  or  a  hemorrhagic  effusion  is 
highly  characteristic. 

Involvement  of  the  lungs  can  be  described  as  occurring  in 
three  stages.  There  is  first  a  fine  bronchitis  of  the  smallest 
tubes  over  both  lungs,  especially  at  the  apices,  and  associated 
with  dry  pleurisy  in  patches.  The  physical  signs  are  those 
of  fine  bronchitis  and  dry  pleurisy.  As  the  tubercles  increase 
in  number  they  coalesce,  so  that  parts  of  the  lungs,  especially 


136        MAXr.lL    OF   THE    rRACTICE    OF  MFD/CLYF. 

the  apices,  become  consolidated,  giving  rise  to  areas  of  dul- 
ness,  to  bronchial  voice  and  breathing,  and  to  increased 
vocal  fremitus.  In  the  third  stage  the  coalesced  tubercles 
break  down  to  form  small  cavities,  so  that  the  breathing  be- 
comes broncho- cavernous  and  there  are  gurgles.  The  sub- 
jective symptoms  consist  of  cough,  rapid  breathing,  rarely 
a  feeling  of  dyspnoea,  slight  cyanosis,  and  an  expectoration 
of  muco-pus  sometimes  admixed  with  blood  and  containing 
bacilli. 

Involvement  of  the  peritoneum  is  shown  by  ascites,  tym- 
panites, constipation,  and  sometimes  by  pain.  In  other 
cases  there  may  be  no  symptoms  although  the  peritoneum 
be  extensively  involved. 

Tubercles  in  the  choroid  can  be  detected  by  expert 
ophthalmologists. 

In  all  cases  the  diagnosis  is  made  by  adding  the  general 
to  the  local  symptoms.  In  some  cases  the  general  outweigh 
the  local  symptoms,  and  the  disease  resembles  malarial 
or  typhoid  fever.  In  other  cases  the  local  symptoms  are 
the  more  prominent,  and  the  cases  resemble  meningitis, 
pleurisy,  broncho-pneumonia,  or  peritonitis. 

Types  of  the  Disease. — i.  Fever  Type. — The  disease  be- 
gins like  typhoid  and  runs  for  three  or  four  weeks,  with 
enlarged  spleen.  There  are  no  hemorrhages  and  no  spots; 
bronchitis  is  more  marked,  the  pulse  and  breathing  are  more 
rapid,  and  the  mind  is  clear.  At  the  end  of  this  time  the 
patient  may  die,  and  the  diagnosis  may  be  difficult  unless 
advancing  lesions  in  the  lungs  and  bacilli  in  the  sputum  can 
be  demonstrated.  Other  cases  go  on  for  three  or  four 
months,  with  high  remittent  fever,  developing  areas  of  con- 
solidation and  breaking  down  in  the  lungs,  and  die  ex- 
hausted. In  these  cases  the  lungs  are  the  seat  of  the  chief 
deposits.  Other  cases  run  the  same  course,  but  we  have 
in  addition  the  local  symptoms  from  other  organs  (see 
PI.  11).  In  still  other  cases  the  temperature  at  the  onset 
is  intermittent,  resembling  malarial  fever. 

2.  Meiiiugeal  Type. — Here  the  picture  is  that  of  tubercular 
meningitis.  The  difference  between  tubercular  meningitis 
in  children  and  in  adults  has  been  alluded  to. 


L4th  "Week. 

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ACUTE   M/I./ARY   TUJiEKCULOSlS.  1 37 

3.  Mania  or  Delirium  Type. — Acute  mania  or  active  talk- 
ative delirium  may  be  the  first  symptom,  associated  with 
fever.  Stupor  and  coma  follow,  and  death  results,  usually 
within  three  weeks. 

4.  Pulmonary  Type. — There  may  be  a  pleurisy  with  fever 
out  of  proportion  to  the  apparent  lesion,  or  the  disease  may 
begin  as  a  bronchitis  or  a  broncho-pneumonia.  Any  bron- 
chitis which  persists  for  some  weeks,  with  high  fever,  rapid 
pulse,  and  respiration  with  fine  rales  heard  especially  at  the 
apices,  should  be  regarded  with  suspicion. 

5.  Any  of  the  preceding  types  may  be  complicated  by 
symptoms  of  a  pre-existing  local  tubercular  lesion. 

Diagnosis  is  aided  by  the  following  characteristics  :  In 
most  cases  there  is  a  previous  tubercular  lesion.  There  is 
evidence  of  a  diffused  disease,  such  as  meningitis,  double 
pleurisy,  and  bronchitis,  in  the  same  patient.  Objective 
symptoms  are  more  marked  than  are  the  subjective  ones. 
The  patient  "  feels  all  right  "  and  yet  is  evidently  sick.  In 
most  cases  bacilli  can  be  demonstrated  in  the  sputa  and 
tubercles  can  be  seen  in  the  choroid. 

There  is  an  advancing  lesion  in  the  lung,  with  diffused 
fine  rales,  both  bronchial  and  pleural ;  later,  consolidation 
and  breaking  down  in  small  areas. 

In  all  cases  the  disease  runs  a  progressively  downward 
course  and  terminates  fatally.  Removal  of  pleuritic  or 
ascitic  accumulations  is  followed  by  a  return  of  the  effu- 
sion. 

Prognosis. — The  disease  is  surely  fatal.  Some  cases  are 
fatal  in  from  seven  to  ten  days ;  more  commonly  they  run 
for  three  or  four  weeks  or  as  many  months,  and  very  rarely 
for  a  year.  Meningeal  cases  are  more  rapid  than  the  fever 
or  the  pulmonary  type. 

Treatment  is  entirely  symptomatic.  The  patient  is  to  be 
fed,  nursed,  and  made  comfortable. 

The  sputa  should  be  sterilized  to  prevent  the  spread  of 
the  disease. 


I3S        JLl.Vr.-lL    OF  THE   PRACTICE    OF  MEDICINE. 

MALARIA  (PALUDISM).' 

Definition. — "  A  specific  infectious  disease  caused  b\-  the 
haiinatozoa  of  Laveran.and  characterized  cHnically  by  very 
variable  types  of  fever — some  regularly  intermittent,  others 
remittent  or  continuous — which  variations  appear  to  depend 
upon  differences  in  the  form  and  mode  of  i^rowth  of  the 
infecting  organism  "  (Osier). 

Etiology. — Parasitology. — The  malarial  parasites  of  man 
belong  to  a  large  family  of  organisms  which  live  and  are 
developed  within  the  red  blood-cells  of  many  kinds  of 
animals.  Their  existence  within  the  red  corpuscles  of 
amphibia,  reptiles,  birds,  and  mammals  has  been  proven. 
For  all  these  parasites  the  name  "  haemosporidia  "  has  been 
adopted.  We  now  know  that  the  haemosporidia  of  malaria 
of  man,  like  thrit  of  birds,  have  two  life-cycles ;  the  one, 
asexual,  in  the  blood  of  malarial  beings  ;  the  other,  sexual, 
in  the  body  of  special  mosquitoes. 

In  man  they  go  through  an  undetermined  number  of  life- 
cycles  ;  they  then  pass  into  the  middle  intestines  of  certain 
species  of  mosquitoes  (Anopheles  claviger,  for  instance),  in 
which  they  go  through  the  various  phases  of  a  new  life- 
cycle  which  ends  in  the  poison-producing  salivary  glands 
of  the  host.  From  there  they  are  injected  by  the  mosquito, 
by  means  of  its  proboscis,  into  the  human  body.  The  phase 
of  life  completed  in  man  is  the  cause  of  malarial  fe\'er. 

There  are  three  distinct  species  :  first,  the  quartan  ;  second, 
the  tertian;  third,  the  ?estivo-autumnal  tertian,  and  more 
rarely  the  aestivo-autumnal  quotidian  (distinguished  from 
that  pseudo-quotidian  which  results  from  a  double  tertian 
or  a  triple  quartan).  Very  rarely  a  mixed  infection  of  any 
two  of  these  three  forms  is  met  with.  The  first  two  species 
give  rise  to  the  milder  forms  of  infection,  the  third  to  the 
severer  forms.  That  these  three  forms  are  distinct  can  be 
demonstrated  by  inoculation  experiments. 

The  cycle  completed  in  man  is  essentially  the  same  in  all 

three  forms. 

'  For  the  article  on  Malaria  the  author  is  indebted  to  Dr.  A.  R.  Stem, 
House  Physician  of  Bellevue  Hospital,  New  York. 


MALARIA.  1 39 

{A)  Hyaline  Forms. — In  the  earlier  stages  of  its  growth — 
i.  e.,  during  and  soon  after  the  chill — the  organism  appears 
in  the  blood-plasma  and  within  the  red  corpuscles  as  a 
small,  motile,  non-pigmented  body,  pale  green  in  color. 
Practically,  however,  it  is  never  seen  outside  the  red  cor- 
puscle. 

{B)  Pigmented  Forms. — Soon  after  the  entrance  of  the 
above-mentioned  hyaline  bodies  into  the  red  corpusles,  the 
organism  is  seen  to  contain  pigment.  This  pigment  (mel- 
anin) represents  the  residue  of  the  digestion  of  haemoglobin 
by  the  organism.  The  active  movement  exhibited  by  the 
pigment  is  unlike  anything  else  seen  in  the  blood,  and  when 
once  recognized  can  never  be  mistaken  for  anything  else. 
As  the  paroxysm  draws  near,  the  pigment  works  in  toward 
the  center  and  is  collected  there  in  a  solid  mass.  Around 
this  mass  of  pigment  radiating  lines  appear,  causing  the 
organism  to  look  like  a  rosette. 

(^C)  Segmenting  Forms. — Around  the  central  pigment 
mass  there  will  be  seen  the  indistinct  outlines  of  a  group  of 
small  colorless  bodies,  which  are  the  new  generation  of 
young  organism.  This  is  followed  by  the  disappearance  of 
the  cell-wall  of  the  red  corpuscle.  It  would  be  expected 
that  these  organisms,  the  young  hyaline  form,  would  be 
found  free  in  the  circulating  blood,  but  this  is  seldom 
observed,  the  next  evidence  of  the  organism  appearing  as 
a  hyaline  body  inside  the  red  corpuscle.  The  cycle  is  thus 
completed. 

'     [D)    (i)    Flagellate    Forms. — (2)    Pigmented    leucocytes. 
(3)  Crescents  and  avoids.     (4)  Extra-corp7iscidar  organisms. 

(i)  Flagellate  Bodies. — Rarely  in  the  fresh  specimen,  and 
occasionally  by  special  staining,  one  is  able  to  demonstrate 
small  flagella  projecting  from  the  malarial  organism.  In  the 
fresh  specimen  they  are  seen  knocking  the  red  cells  about 
in  a  very  lively  manner.  It  is  now  supposed  that  they 
represent  the  sexual  organisms,  which  are  capable  of  further 
development  if  taken  up  by  the  mosquito,  but  which  degen- 
erate and  disappear  if  they  remain  in  man. 

(2)  Pigmented  leucocytes  containing  the  whole,  or  parts  of 
the   malarial   organism,  or   merely  blocks  of  granules,  are 


140        MA.\C:iL    OF   THE   PK.ICTICE    OF  MEDICIXE. 

occasionally  seen   in  the  blood.     When  seen,  the}-  are  of 
diagnostic  value. 

(3)  Crescents  and  Oz'oiiis. — These  are  observed  only  in 
cases  of  a^stivo-autumnal  fever.  They  are  derived  directly 
from  the  pigmented  intracellular  forms.  Their  extremities 
are  usually  rounded  off,  and  are  joined  by  a  delicate  curved 
line  bridging  over  their  concave  border,  which  is  supposed 
to  be  the  remains  of  their  original  host.  From  these  organ- 
isms, which  occasionally  are  seen  to  throw  out  flagella, 
starts  the  sexual  life-cycle  of  the  ai^stivo-autumnal  organism 
if  taken  up  by  the  mosquito. 

(4)  Extracorpuscular  Pigmented  Organisjns. — Some  of 
the  organisms  (when  the}-  have  arrived  at  maturity),  instead 
of  undergoing  segmentation  within  the  red  cells,  may  be 
seen  to  leave  their  hosts  and  appear  as  such  in  the  blood. 

The  principal  characteristics  of  the  tertian,  the  quartan, 
and  the  aestivo-autumnal  forms  are  as  follows : 

(i)  The  asexual  life-cycle  of  the  quartan  form  is  com- 
pleted in  three  days,  tliat  of  the  tertian  and  aestivo-autumnal 
forms  in  two  days. 

(2)  The  tertian  and  quartan  invade  nearly  the  whole  of 
the  red  cell ;  the  sestivo-autumnal  occupies  but  one-quarter 
of  the  red  cell. 

(3)  The  quartan  and  aestivo-autumnal  do  not  enlarge  the 
red  cell  in  which  they  grow  ;  the  tertian  does. 

(4)  The  amoeboid  movement  in  the  tertian  and  aestivo- 
autumnal  is  very  active ;  in  the  quartan  it  is  very  sluggish. 

(5)  The  pigment  in  the  tertian  is  finely  granular,  consider- 
able in  amount,  and  moves  actively;  in  the  quartan  it  is 
coarse,  small  in  amount,  and  moves  but  feebly ;  in  the 
aestivo-autumnal  it  is  ver)^  fine,  almost  invisible,  fairly  large 
in  amount,  and  moves  actively. 

(6)  The  amoebulae  in  the  quartan  are  six  to  fourteen  in 
number;  twelve  to  twenty  in  the  tertian  and  aestivo-au- 
tumnal. 

To  study  the  development  of  the  aestivo-autumnal  para- 
site the  blood  must  be  obtained  from  the  spleen,  bone- 
marrow,  or  other  internal  organs,  as  these  organisms  dis- 
appear into  the  internal  organs  just  before  segmentation,  or. 


MALARIA.  141 

as  it  is  called,  sporulation  takes  place.  The  quartan  and 
tertian  organisms  can  be  studied  throughout  their  entire 
development  in  the  circulating  blood. 

Sources  of  Malarial  Infection. — Man  is  the  undeniable 
source  of  infection.  When  a  healthy  man  is  inoculated  with 
even  a  minute  quantity  of  malarial  blood,  this  type  of  fever 
is  reproduced.  A  malarial  person  can,  however,  mix  freely 
with  others  without  conveying  the  disease  to  them,  provided 
there  are  no  mosquitoes  about.  The  process  of  develop- 
ment of  the  malarial  organism  is  analogous  to  that  of  the 
taenia.  The  theory  that  malaria  is  a  disease  of  the  soil,  and 
that  drinking  water  is  a  direct  source  of  infection,  is  no  longer 
held.  It  is  now  generally  accepted  that  the  mosquito  (Ano- 
pheles) is  the  main  source  of  infection  to  man ;  that  this 
mosquito  exists  in  all  localities  where  malaria  abounds ;  that 
the  skin  is  the  only  portal  of  entry  for  the  virus  ;  and  that 
no  mosquito  is  born  infected,  but  must  receive  its  virus 
from  some  malarious  person.  The  genera  most  frequently 
found  in  malarious  districts  are  the  Culex  and  the  Ano- 
pheles. So  far  as  the  transmission  of  the  malarial  organism 
to  man  is  concerned,  the  Culex  is  perfectly  harmless.  A 
good  working  rule  for  the  differentiation  of  these  two  species 
is  that  the  Anopheles  has  palpi  as  long  as  the  proboscis,  and 
spotted  wings.  "  It  is  interesting  to  note  that  the  Anopheles, 
which  are  undoubtedly  injurious,  do  not  make  a  humming 
noise  while  flying,  and  that  their  bites  are  less  irritating  than 
those  of  the  Culex."  It  frequently  happens  that  people  are 
unconscious  of  having  been  bitten. 

Racial  Predisposition. — Whites  seem  to  be  more  suscep- 
tible than  the  blacks,  and  are  also  more  liable  to  the  severer 
forms  of  the  disease.  Strangers  are  more  susceptible  than 
natives,  who  appear  to  acquire  a  certain  power  of  resistance. 

Age. — Malaria  spares  no  age.  Infants  and  children, 
however,  seem  to  be  more  susceptible  than  adults. 

Sex. — Men  and  women,  being  equally  exposed,  suffer 
equally. 

Occupation. — Those  who  work  in  the  outskirts  of  a  city, 
where  the  soil  is  upturned,  or  in  marshy  places  are  more 
apt  to  become  infected.     Excessive  labor,  insufficient  food. 


142        M.l.Vl'.IL    OF   THE   PRACTICE    OF  MEDJCIXE. 

or  chilling  of  the  body  ma}'  predispose  to  an  attack  or 
hasten  a  relapse. 

Season. — Those  who  live  in  infected  districts  are  more  apt 
to  contract  the  disease  in  summer  and  autumn  than  in  winter 
and  spring. 

Ti)nc  of  Day. — Those  exposed  at  night  are  more  apt  to 
become  infected  than  those  exposed  during  the  day. 

Cli)>iatic  Injluoiccs. — Heat  is  most  important.  "  Malaria 
rarely  extends  bej'ond  64°  of  North  latitude  and  57°  of 
South  latitude "  (Hertz).  As  we  near  the  equator  the 
disease  increases  steadily  in  severity  and  persistence. 

Altitude. — People  living  in  the  upper  stories  of  a  house 
are  not  so  apt  to  contract  the  disease  as  those  living  on  the 
ground  floor.  (The  mosquito  does  not  fl}'  a  great  distance 
from  the  ground.) 

Telluric  Conditions. — Anything  that  results  in  the  forma- 
tion of  pools  of  stagnant  water  may  be  productive  of  a 
malarial  endemic,  as  this  condition  favors  the  growth  of  the 
larvae  of  the  mosquitoes. 

Immunity. — No  race  is  absolutely  immune.  Negroes 
are  less  subject  than  the  whites  to  the  pernicious  forms, 
and,  having  once  become  infected,  they  acquire  relative 
immunity  more  easily  than  do  the  whites.  Congenital 
and  in  some  instances  "  family "  immunity  undoubtedly 
exists.  Acquired  immunity  after  several  attacks  is  not 
so  very  rare. 

Patholog-y. — Within  the  organs  of  persons  who  have  died 
of  malaria  there  are  found,  first  of  all,  the  malarial  parasites 
containing  pigment  and  lying  more  or  less  intravascularly. 
In  the  aestivo-autumnal  variety  the  organism  is  found  princi- 
pally in  the  spleen,  bone-marrow,  and  liver.  The  character- 
istic lesions  in  all  cases  are  certain  changes  in  the  blood, 
spleen,  and  liver.  In  the  more  intense  and  acute  forms 
numerous  pigment  particles  are  found  in  the  blood.  These 
particles  are  either  free  in  the  blood,  or  imbedded  in  the 
leucocytes  or  in  the  endothelium  of  the  blood-vessels.  This 
melannsmia  results  directly  from  the  destruction  of  the  red 
cells  by  the  parasites.  The  pigment  is  most  abundant  in 
the  blood-vessels  of  the  spleen  and  the  liver.    In  acute  cases 


MALARIA.  143 

the  spleen  is  regularly  enlarged,  the  capsule  is  tense,  the 
parenchyma  chocolate  colored  or  brown,  very  much  softened, 
and  sometimes  diffluent,  and  in  such  a  condition  it  may  be 
lacerated,  especially  when  there  are  adhesions.  The  liver  is 
usually  somewhat  enlarged,  and  assumes  a  brownish  or 
blackish  color.  In  the  severer  forms  extravasation  of  blood 
from  the  mucous  membranes  and  into  their  substance  may 
take  place.  There  may  be  jaundice.  Focal  necroses  in  the 
viscera,  similar  to  those  seen  in  other  acute  infectious  dis- 
eases, have  been  described.  Acute  exudative  nephritis  is 
not  infrequently  seen.  Thromboses  of  internal  vessels  have 
been  reported,  at  times  the  greater  part  of  the  thrombus 
consisting  of  malarial  organisms.  In  thd  protracted  cases  the 
liver  and  spleen  frequently  show  cirrhotic  changes.  At 
times  the  hypertrophy  of  the  spleen  is  enormous — "  ague- 
cake  " — and  may  extend  to  the  umbilicus  and  even  beyond. 
The  blood  regularly  becomes  markedly  anaemic.  As  a 
rule,  the  corpuscles  and  haemoglobin  are  diminished  pro- 
portionately (secondary  ansemia).  At  times  it  may  be  so 
severe  as  to  resemble  pernicious  anaemia.  In  convalescence 
the  restitution  of  haemoglobin  is  often  incomplete.  There  is 
usually  a  leucopenia.  The  differential  count  shows  a  lympho- 
cytosis. 

Symptoms. — hiaibation. — As  in  the  other  infectious  dis- 
eases, there  is  a  period  of  incubation  from  the  moment  of 
entrance  of  the  parasite  into  the  system  to  the  development 
of  the  disease.  The  disease  is  frequently  so  mild  that  it  is 
unobserved  by  the  patient.  In  some  instances  the  disease 
manifests  itself  only  after  the  patient  has  left  the  very  mala- 
rious district  and  moved  to  another  locality.  According  to 
recent  experiments,  the  periods  of  incubation  of  the  various 
types  are  as  follows :  Quartan,  about  fourteen  days  ;  tertian, 
eleven  days  ;  aestivo-autumnal,  six  days.  During  the  period 
of  incubation  the  patient  may  suffer  from  headache,  consti- 
pation, a  coated  tongue,  and  malaise. 

A.  Regular  Malarial  Fevers ;  Intermittents. — There  are 
two  important  types,  the  tertian  and  the  quartan. 

The  tertian  is  common  in  temperate  climates.  Single 
tertian  implies  that  there  is  a  paroxysm  every  forty-eight 


144        .V.-iXr.lL    OF   THE   PRACTICE    OF  MEDICINE. 

hours.  In  double  tertian  or  pseudo-quotidian  there  is  a 
paroxysm  every  twenty-four  hours. 

The  quartan  is  very  rare  in  this  latitude.  The  paroxysms 
come  every  seventy-two  hours.  In  double  quartan  there 
are  paroxysms  occurring  on  two  succeding  days,  followed 
by  a  third  day  which  is  free  from  an}'  paroxysm.  In  triple 
quartan  or  pseudo-quotidian  there  is  a  paroxysm  eveiy  day. 

PlioiODicna  of  t)ic  Attack. — The  ordinary  paro.xysm  is 
divided  into  three  stages — /.  c,  the  chill,  the  fever,  and  the 
sweating.  CJiill.  Marked  by  chilly  sensations,  especially 
along  the  spine,  yawning,  and  the  development  of  "goose- 
flesh  "  ;  nausea,  vomiting,  and  headache  may  be  present. 
The  pulse  is  rapid.  At  this  stage  the  temperature  has 
already  risen,  and  then  a  violent  shaking  chill  sets  in.  The 
face  becomes  pale ;  the  teeth  chatter ;  the  whole  body  feels 
icy  cold  and  looks  bluish.  The  patient  seeks  extra  bed- 
clothing  or  huddles  up  near  the  fire.  The  surface  ther- 
mometer indicates  a  reduction  of  the  temperature.  The 
rectal  temperature  may  reach  107°  F.  This  stage  lasts 
from  fifteen  minutes  to  two  hours.  Fever.  The  surface  cold- 
ness gradually  disappears  ;  the  skin  becomes  hot  and  dry ; 
the  entire  body  becomes  flushed ;  the  heart-action  becomes 
forcible ;  the  pulse  full  and  strong.  The  headache  becomes 
aggravated  and  throbbing.  The  temperature  during  this 
stage  may  be  higher  than  during  the  chill,  but  it  usually 
begins  to  decline.  Delirium  sometimes  occurs.  This  stage 
lasts  for  from  one  to  four  hours.  Szt'cathi^s^.  This  stage 
begins  with  the  appearance  of  moisture  on  the  skin  ;  gradu- 
ally the  whole  body  becomes  bathed  in  a  profuse  perspira- 
tion. All  the  untoward  symptoms  abate  and  the  patient 
sinks  into  a  refreshing  sleep.  The  uniformity  in  the  dura- 
tion of  the  paroxysms  is  remarkable.  Albuminuria  may  be 
present.  The  spleen  may  enlarge,  and  in  children  convul- 
sions may  occur. 

Tune  of  Recurrence. — The  recurrence  of  the  paroxysm  is 
usually  at  the  same  hour.  As  the  disease  progresses  there 
is  frequently  a  tendency  to  "  anticipation  ;  "  in  some  cases 
there  may  be  "retardation." 

B.  Irregular  Malarial  Fevers. — .Spring  and  early  summer 


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MALARIA.  145 

infections  are  usually  intermittent.  Late  summer  and 
autumn  cases  are  characterized  by  a  large  number  of  irregu- 
larly intermittent,  of  continuous  and  remittent,  and  of  the 
pernicious  fevers. 

{a)  Irregular  bitermittenis. — Autumnal  are  less  definite 
than  the  spring  agues.  The  paroxysms  are  longer  and  tend 
to  approach  each  other ;  by  coalescence  we  may  get  a 
pseudo-crisis.  In  very  mild  cases  either  the  chill,  the  fever, 
or  the  sweating  may  be  absent. 

{F)  Continuous  and  Re^nittent  Malarial  Fevers. — In  the 
beginning  there  is  usually  general  malaise,  and  occasionally 
nausea  and  vomiting.  The  disease  may  set  in  with  a  violent 
chill,  and  chilly  sensations  may  recur  for  several  days. 
Gastric  symptoms  may  be  marked.  The  fever  may  be  con- 
tinuous, with  daily  remissions,  or  there  may  be  remissions 
or  intermissions  at  short  intervals.  There  may  be  jaundice. 
The  general  appearance  maybe  suggestive  of  typhoid  fever. 
The  cases  vary  greatly  in  severity.  The  fever  may  subside 
in  a  few  days,  or  persist  for  two  weeks  or  more.  Delirium, 
coma,  and  hemorrhage  are  not  very  uncommon. 

{c)  Pernicious  Malarial  Fevers. — These  are  rare  in  tem- 
perate climates.  The  following  are  the  most  important 
forms:  (i)  TJic  comatose  form.  Complete  unconsciousness 
following  delirium  or  coming  on  suddenly.  Unconscious- 
ness may  persist  for  from  twelve  to  twenty-four  hours,  and 
the  patient  may  die  in  coma,  or  he  may  recover  conscious- 
ness and  die  in  a  second  attack.  This  is  seen  most  fre- 
quently in  the  neglected  cases,  and  is  not  confined  to  the 
sestivo-autumnal,  but  is  seen  also  in  tertian  and  quartan 
infections.  Few  parasites  are  found  in  the  circulation  in 
many  cases  (Ewing).  (2)  Algid  form.  Complete  collapse, 
usually  with  gastro-intestinal  s^^mptoms,  with  or  without 
delirium  or  stupor.  (3)  HemorrJiagic  form.  Characterized 
by  bleeding,  usually  from  the  kidneys.  (4)  Gastro-enteric 
form.  Has  for  its  prominent  symptoms  gastro-intestinal 
symptoms  with  moderate  collapse,  resembling  the  third 
week  of  typhoid  fever. 

C.  Malarial  Cachexias. — Its  two  distinguishing  features 
are  anaemia  and  enlarged  spleen.      The  spleen  is  usually 

10 


146        J/.-l.Vr.lL    OF  THE   PRACTICE    OF  MEDICI.VE. 

liard,  smooth,  and  not  tender.  Tlie  an?emia  is  secondan- 
and  may  be  ven'  marked.  It  occurs  especially  in  those  who 
have  li\ed  for  a  time  in  malarious  districts  or  have  been 
imi)roperly  treated.  They  may  not  have  had  typical 
malarial  attacks.  The  principal  symptoms  are  headache, 
constipation,  bilious  attacks,  increasinij  anaemia  (skin 
"  muddy  yellow "),  tendency  to  hemorrhages,  irregular 
fever,  paroxysmal  neuralgias,  especialh-  supra-orbital,  jaun- 
dice, and  mental  depression. 

Complications  and  Sequelae. — Acute  catarrhal  colitis. 
Acute  degenerative  or  exudative  nephritis,  occasionally 
spontaneous  rupture  of  the  spleen,  and  very  rarely  acute 
lobar  pneumonia,  ha\-e  been  found  to  complicate  malaria. 
Whether  or  not  typhoid  can  run  concurrently  with  malaria 
is  still  in  doubt.  Cases  of  so-called  "  typho-malaria  "  are 
usually  "  enterica."  According  to  Ewing,  malarial  parasites 
are  never  found  during  typhoid  except  at  the  beginning  of 
the  disease  or  during  convalescence.  This  author  also  says 
that  typhoid  fever  is  to  a  large  extent  incompatible  with 
malaria,  and  that  during  the  course  of  the  former  the  latter 
infection  is  usually  suppressed.  This  opinion,  however,  is 
not  generally  held,  for  some  {&\\  cases  have  been  reported 
by  competent  observers  in  which  the  malarial  organism  was 
found  in  the  process  of  sporulation  while  the  typhoid  fever 
was  at  its  height. 

Diagnosis. — The  diagnosis  of  all  forms  of  malaria  is 
simplified  by  finding  in  the  blood  the  plasmodium,  and  by 
the  subsidence  of  the  disease  upon  the  administration  of 
quinine.  It  has  been  asserted  that  splenic  puncture  is 
occasionally  needed  for  diagnostic  purposes.  This  pro- 
cedure, however,  is  not  alone  very  dangerous,  but  also 
unnecessar}\  "  In  every  case  in  which  pigment-bearing 
leucocytes  are  observed  in  the  blood,  malaria  should  be 
suspected,  as  a  melanaemia  has  so  far  only  been  observed 
in  this  disease,  relapsing  fever,  and  in  connection  with  rare 
melanotic  tumors  "  (Simon).  It  is  important  to  bear  in  mind 
that  malaria,  typhoid,  and  tuberculosis  are  the  only  febrile 
diseases  that  are  regularly  accompanied  by  a  leucopenia. 
Septicaemic   fever,  such   as   that   of  advanced   tuberculosis, 


MALARIA.  147 

puerperal  fever,  empyema,  and  ulcerative  endocarditis  are 
frequently  mistaken  for  malaria.  Here  also  we  get  re- 
curring chills  with  fever  and  sweating,  but  the  attacks  are 
not  as  regularly  periodical  and  intermittent,  the  chills  are 
not  so  regular  and  less  violent.  Sometimes  the  fever  is  in- 
termittent, sometimes  remittent.  Septicaemia  almost  always 
gives  a  hyperleucocytosis,  and  such  fevers  do  not  respond 
to  quinine.  The  malarial  organism  is  not  present.  The 
search  for  a  local  cause  for  the  septicaemia  should  not  be 
neglected.  Typhoid  is  to  be  differentiated  from  severe 
malaria  by  the  history,  blood-examination,  serum  test,  diazo 
reaction  of  the  urine,  the  continuous  temperature,  which  is 
usually  absent  in  malaria,  and  by  the  general  symptom- 
atology. Marked  splenic  hypertrophy  in  chronic  malaria 
(the  so-called  "  ague-cake  ")  may  have  to  be  differentiated 
from  Splenic  Leukaemia.  The  history  of  malarial  cachexia, 
the  absence  of  lymphatic  enlargements,  and  the  blood- 
examination,  showing  a  leucopenia  as  contrasted  with  the 
marked  hyperleucocytosis  of  the  latter  disease,  are  usually 
sufficient  to  make  a  diagnosis. 

Method  of  Examination  of  the  Blood. — If  made  purely  for 
diagnostic  purposes,  the  fresh  specimen  is  to  be  preferred 
to  all  others.  In  looking  for  the  malarial  organism  it  is 
well  to  bear  in  mind  that  if  the  iris  diaphragm  is  kept  well 
open,  the  moving  pigment  particles  are  more  easily  recog- 
nized. These  moving  pigment  particles  resemble  nothing 
else  in  the  blood,  and  when  once  recognized  can  never  be 
forgotten.  Movement  of  the  pigment  can  occasionally  be 
seen  an  hour  after  the  preparation  of  the  fresh  specimen. 
If  the  examination  cannot  be  made  within  this  time,  the 
slide  must  be  fixed  and  stained.  After  allowing  the  slide 
to  dry  thoroughly  in  the  air,  it  is  fixed  according  to  the 
stain  employed.  For  the  methods  of  preparation  of  a  slide 
the  reader  is  referred  to  Cabot's  book  on  The  Blood.  For 
rapid  work  the  best  results  are  to  be  obtained  with  the 
thionin  and  Jenner  stains.  In  staining  with  the  former  the 
dry  smears  are  fixed  in  a  mixture  of  25  per  cent,  of  formal- 
dehyde and  strong  alcohol.  This  mixture  can  most  easily 
be  made  by  adding  5  drops  of  a  4  per  cent,  formaldehyde 


148        MAXfAL    OF   THE  PRACTICE    OF  MEDICINE. 

solution  to  10  c.c.  of  alcohol  and  using  immediately,  as  It 
does  -not  keep.  Fixation  is  complete  in  one  minute.  The 
stain  is  made  by  adding  20  c.c.  of  thionin  in  50  per  cent, 
alcohol  to  100  c.c.  of  a  2  per  cent,  carbolic-acid  solution. 
Stain  the  smears  in  this  mixture  for  fifteen  to  thirty  seconds. 
Wash  off  in  water,  dry,  and  examine  with  an  oil  immersion 
lens.  By  this  method  only  the  plasmodia  and  the  nuclei 
are  stained,  while  the  red  cells  are  a  faint  greenish  yellow 
which  contrasts  sharply  with  the  purple  of  the  plasmodia. 
The  Jcnncr  stain  is  prepared  as  follows :  Equal  parts  of  a 
1.2  per  cent,  to  a  1.25  per  cent,  aqueous  solution  of  Grijbler's 
eosine,  yellow  shade,  and  of  a  i  per  cent,  aqueous  solution 
of  methylene-blue  are  mixed  in  an  open  basin,  thoroughly 
stirred,  and  set  aside  for  twenty-four  hours.  The  resulting 
precipitate  is  filtered  off,  dried,  powdered,  washed  with 
water,  and  again  filtered  and  dried.  Of  the  dye  which  has 
thus  been  prepared,  a  5  per  cent,  solution  in  pure  methyl 
alcohol  is  made,  to  which  10  per  cent,  of  glycerine  is  added. 
After  the  specimens  are  dried  in  the  air,  without  further 
fixation,  they  are  well  covered  with  the  stain  and  then 
covered  with  a  Petri  dish  (to  prevent  evaporation)  for 
from  one  to  four  minutes,  depending  upon  the  freshness 
of  the  stain.  They  are  next  washed  thoroughly  in  water 
until  the  purple  stain  has  changed  to  a  mahogany  color 
(about  thirty  seconds).  The  specimen  is  then  dried, 
and  is  ready  for  examination.  The  advantage  of  this 
stain  is  that  one  is  thereby  enabled  to  stain  rapidly 
without  previous  fixing.  At  the  same  time  it  allows  of  a 
differential  count  and  an  examination  for  bacteria  to  be 
made.  For  the  demonstration  of  the  chromatin  of  the 
nucleus  of  the  plasmodium  the  modification  of  the  Roman- 
owsky  stain  suggested  by  Nocht  is  the  simplest.  For 
details  of  this  and  other  stains  the  reader  is  referred  to  the 
recent  book  by  Dr.  Wood,  and  to  the  latest  edition  of  C. 
E.  Simons'  work  on  Clinical  Diagnosis. 

Prognosis. — Here  we  have  to  consider  the  nature  of  the 
infection,  the  locality  and  season  in  which  it  was  contracted, 
as  well  as  individual  conditions.  In  the  mild  fevers  the 
prognosis  is  usually  good.     In  these  fevers  the  number  of 


MALARIA.  149 

organisms  found  in  the  circulating  blood  gives  us  in  most 
instances  an  index  of  the  severity  of  the  infection.  We 
must  bear  in  mind  that  relapses  may  occur  for  a  long  time, 
and  if  a  patient  continues  to  live  under  bad  hygienic  condi- 
tions, cachexia  may  follow.  Spontaneous  recovery  occasion- 
ally occurs,  but  these  cases,  if  untreated,  almost  always  have 
relapses  within  a  month  or  two.  In  the  aestivo-autumnal 
infection  the  prognosis  is  not  so  bad  as  older  writers  would 
lead  us  to  suppose,  more  especially  in  those  cases  where  the 
progress  of  the  disease  is  checked  before  the  crescents  have 
developed.  In  the  pernicious  forms  the  prognosis  is  usually 
grave.  Here  the  occurrence  of  previous  attacks  must  be 
taken  into  consideration,  for  in  this  event  the  prognosis  is 
always  bad,  although  there  are  reported  recoveries  from  a 
second  and  even  a  third  attack.  In  these  cases  the  number 
of  parasites  in  the  circulating  blood  is  not  a  fair  index  of 
the  severity  of  the  disease.  The  pernicious  fevers  arranged 
in  the  order  of  their  relative  gravity  would  be :  Cerebral, 
hemorrhagic,  gastro-intestinal,  and  algid.  The  prognosis 
of  malarial  cachexia  depends  upon  the  time  it  has  existed, 
the  severity  of  the  anaemia,  and  the  hygienic  conditions 
existing. 

Prophylaxis. — Means  adopted  in  this  direction  depend 
to  a  great  extent  upon  the  location  dealt  with.  In  the 
tropical  climates  the  problem  is  a  most  serious  one,  for  here 
the  disease  appears  to  be  gaining  rather  than  losing  in  both 
extent  and  severity.  Fortunately,  in  the  vicinity  of  New 
York  the  problem  is  much  more  hopeful.  It  has  been 
suggested  that  all  cases  of  malaria  be  reported  to  the  Board 
of  Health  and  isolated.  This  measure,  however,  appears  as 
yet  to  be  somewhat  too  radical,  and  would  hardly  meet 
with  general  approval.  It  seems  practical,  however,  to 
appoint  inspectors,  to  instruct  the  occupants  of  infected 
houses  or  districts  in  the  measures  to  be  employed  for  the 
destruction  of  the  Anopheles,  to  provide  proper  screening 
of  houses,  and  to  supervise  in  the  filling  up,  draining,  stock- 
ing with  fish,  or  petrolizing  of  all  stagnant  pools  in  the 
vicinity.     Quinine  should  be  insisted  upon,  and  furnished 


I50        MAXr.lL    OF   THE    PKACTICE    OF  MFDIChVE. 

gratis  when  necessary.  Proper  food  and  water  are  essential. 
The  season  and  the  hours  for  work  in  malarious  districts 
should  be  carefully  selected.  Houses  should  be  built  in  as 
elevated  a  position  as  possible.  They  should  be  exposed  to 
the  wind,  and  be  as  far  from  stagnant  pools  as  is  practical. 
For  further  information  about  this  most  important  measure 
the  reader  is  referred  to  the  articles  of  Dr.  Berkeley  in  the 
Nciv  York  Medical  Record  of  January  26,  1 901,  and  also  the 
recent  books  of  Celli  and  Bignami  and  Marchiafava. 

Treatment. — Iiitcniiittcnt  Cases. — During  the  paroxysm 
measures  are  employed  to  combat  the  symptoms  from  which 
the  patient  is  suffering.  During  the  chill  external  heat  is  em- 
ployed, and,  if  the  stomach  will  bear  it,  hot  drinks  are  given. 
In  some  cases  small  doses  of  the  tincture  of  capsicum  or  gin- 
ger are  useful.  In  the  hot  stage  exactly  opposite  remedies 
are  employed.  Cold  sponging  is  frequently  comforting  to 
the  patient.  If  necessary,  stimulation  is  employed.  Anti- 
pyretics should  not  be  used.  As  to  the  time  of  the  admin- 
istration of  quinine,  opinions  differ,  but  this  seems  to  make 
very  little  difference,  so  long  as  the  dose  is  large  enough 
and  is  kept  up  for  a  sufficient  length  of  time.  Good  results 
have  been  obtained  from  the  administration  of  quinine  sul- 
phate or  hydrochlorate,  in  capsule  or  preferably  in  solution, 
in  doses  of  5  grains  three  or  four  times  in  twenty-four  hours 
for  one  or  two  weeks,  followed  by  doses  of  2  grains  three 
times  a  day  continued  for  two  months.  Larger  doses  than 
this  are  usually  not  necessary.  Quinine  sometimes  acts 
more  efficaciously  if  preceded  by  a  mercurial  purge.  The 
mixture  of  quinine  and  aromatic  sulphuric  acid  is  very  satis- 
factory. In  some  few  rebellious  cases  evaporated  tincture 
of  Warburg  is  useful.  In  children  quinine-chocolate  tablets 
or  some  other  palatable  form  may  have  to  be  employed. 
/;/  the  continuous  fevers  it  is  occasionally  necessary  to  give 
somewhat  larger  doses,  and  to  continue  the  drug  for  a 
greater  length  of  time.  Warburg's  tincture  sometimes  helps 
these  cases  when  all  other  remedies  have  failed.  The  fol- 
lowing prescription  sometimes  gives  good  results : 


AN71IRAX. 

I^.     Quininae  sulphatis, 

gr.  v; 

Tincturae  opii, 

mv; 

Tincturse  capsici, 

mv.— M, 

Si?,  t.  i.  d. 

151 


In  the  pernicious  types  the  patient  should  be  thoroughly  and 
rapidly  cinchonized.  It  is  usually  impossible  to  do  this  by 
mouth,  owing  to  the  incessant  vomiting,  so  that  hypodermic 
administration  of  one  of  the  soluble  forms  of  quinine  is 
necessary. 

Stimulation  and  feeding  per  rectum  in  severe  cases  is  also 
essential  at  times. 

Malarial  Cachexia. — In  many  of  these  cases  the  parasites 
are  no  longer  present  in  the  blood,  so  quinine  is  of  little  use. 
Mild  cases  do  well  under  proper  hygienic  and  tonic  treat- 
ment, such  as  iron,  arsenic,  and  strychnine.  The  very 
chronic  cases,  with  marked  enlargement  of  the  spleen  and 
liver,  are  usually  very  troublesome.  These  cases  occasion- 
ally resist  all  treatment  and  die  with  the  symptoms  of  per- 
nicious anemia.  Numerous  other  remedies  have  been 
introduced  as  substitutes  for  quinine  in  the  treatment  of 
malaria.     All  of  these,  however,  have  been  proven  inferior, 

ANTHRAX. 

Definition  and  Synonyms. — Anthrax  is  an  infectious 
disease  caused  by  the  anthrax  bacillus.  Syiionyms :  Malig- 
nant pustule  ;  Malignant  oedema ;  Splenic  fever ;  Charbon  ; 
Milzbrand ;  Woolsorter's  disease. 

Etiology. — Anthrax  which  is  primarily  a  disease  of  cattle, 
sheep,  and  horses,  is  occasionally  communicated  to  man.  It 
is  especially  frequent  in  Russia,  Siberia,  in  parts  of  Europe, 
and  in  South  America.  The  bacillus  of  anthrax  was  the 
first  specific  micro-organism  ever  described.  It  is  a  rod 
bacillus  two  to  ten  times  longer  than  the  diameter  of  a  red 
blood-cell,  non-mobile,  with  abundant  spore-growth.  The 
rods  are  often  jointed  together,  forming  long  filaments. 
The  bacilli  are  readily  destroyed,  but  the  spores  are  ex- 
ceedingly resistant,  and  live  for  a  long  time  in  the  grass  or 
on  the  surface  of  pasture-land.  Cattle  acquire  the  disease 
by  eating  the  infected  grass  or  by  inhaling  the  spores. 


152        MAA'UAL    OF  THE   PRACTICE    OE  MEniCLYE. 

.  In  man  the  disease  may  be  acquired  by  inoculation,  by 
inhalation,  or  by  the  alimentary  canal.  Inoculation  results 
from  handling  infected  hides,  wool,  hair,  or  instruments,  or 
b\'  bites  of  flies  or  of  mosquitoes.  The  disease  may  be  ac- 
quired by  inhalations  from  infected  skins  or  wool,  or  the 
alimentary  canal  may  be  infected  from  diseased  meat. 

Symptoms. — The  disease  occurs  in  an  external  and  an 
internal  form. 

I.  Externa/  Form. — {ci)  Malig>ia]it  pustule  is  the  most 
common  form,  and  it  occurs  from  inoculation  of  an  ex- 
posed surface,  usually  the  face.  Symptoms  begin  from  a 
few  hours  to  four  days  after  inoculation,  with  itching, 
pricking,  or  burning  like  the  sting  of  an  insect.  A  papule 
is  formed,  developing  into  a  vesicle  which  ruptures,  dis- 
charges bloody  serum,  and  leaves  a  spot  of  brown  dry 
gangrene  surrounded  by  a  zone  of  red  swollen  skin  which 
may  be  covered  by  vesicles  and  which  resembles  a  carbun- 
cle. There  is  brawny  oedema  of  the  subcutaneous  tissues 
that  may  involve  the  whole  of  an  arm  or  the  side  of  the 
neck  within  thirty- six  hours.  There  are  usually  lymphan- 
gitis and  phlebitis  starting  from  the  infected  areas. 

Constitutional  symptoms  occur  if  the  infection  becomes 
general.  These  symptoms  are  usually  delirium  or  a  tran- 
quil mind,  fever,  sweating,  vomiting,  collapse,  and  death, 
from  heart  failure  or  in  the  typhoid  condition,  in  from  five 
to  eight  days.  If  general  infection  does  not  'occur,  the 
constitutional  symptoms  are  those  which  ordinarily  accom- 
pany a  local  inflammation. 

The  prognosis  is  exceedingly  grave,  although  in  a  large 
number  of  patients  who  recover  the  slough  separates  and 
the  wound  heals.  The  mortality  is  greatly  reduced  if  rad- 
ical treatment  be  resorted  to  at  the  onset. 

{b)  Maligna]it  CEelema. — This  form  occurs  in  regions 
where  the  connective  tissue  is  loose,  as  the  eyelids,  neck, 
and  forearm.  The  skin  may  not  be  discolored,  but  there  is  a 
flat  infiltration  with  ill-defined  borders  and  a  rapidly-spreading 
oedema  which  may  be  of  sufficient  intensity  to  cause  gan- 
grene. Constitutional  symptoms  occur  early,  and  the  disease 
is  almost  invariably  fatal,  although  recovery  is  possible. 


ANTHRAX. 


I'l.AlK  14. 


i 


Bacillus  anthracis  :  cover-glass  preparation  from  spleen  of  white  mouse  {American  Text- 
Book  of  Surge?-}'). 


JIYDROJ'IIO/UA.  153 

2.  Internal  Form. — {a)  Intestinal  Form  (Mycosis  Intesti- 
nalis). — This  form  of  anthrax  is  caused  by  eating  infected 
meat,  and  it  may  affect  a  number  of  people  at  the  same 
time.  The  attack  begins  as  an  acute  infection  with  a  chill, 
fever,  pain  in  the  head  and  back,  with  severe  gastro-intestinal 
symptoms,  vomiting,  and  diarrhoea.  There  is  a  tendency 
to  hemorrhages,  and  metastatic  malignant  pustules  may 
occur  on  the  skin.  There  may  be  delirium  or  convulsions. 
Dyspnoea  and  cyanosis  are  common,  and  death  from  heart 
failure  occurs  in  a  few  days.    These  cases  are  invariably  fatal. 

{b)  Woolsoriers'  Disease. — These  cases  result  from  sorting 
and  picking  infected  hair  and  wool.  There  is  a  chill,  fol- 
lowed by  fever,  pains  in  the  head  and  chest,  dyspnoea,  and 
cough.  Vomiting  and  diarrhoea  are  common.  There  may 
be  a  clear  and  tranquil  mind,  although  delirium  and  uncon- 
sciousness are  frequent.  There  is  increasing  heart  weak- 
ness, and  death  results,  in  collapse  and  extreme  prostration, 
in  from  one  to  seven  days. 

Treatment. — Preventive  treatment  should  be  directed  to 
cattle  and  sheep.  Diseased  animals  should  be  killed  and 
buried  deeply  or  cremated  ;  suspected  animals  should  be 
isolated.  Inoculations  with  attenuated  virus  are  being  em- 
ployed with  considerable  success  in  securing  immunity. 

In  man  the  only  form  amenable  to  treatment  is  the  exter- 
nal pustule.  The  mass  should  be  excised  thoroughly  or  be 
penetrated  by  deep  crucial  incisions  into  which  powdered 
bichloride  of  mercury  is  to  be  sprinkled.  Subcutaneous 
injections  of  a  solution  of  carbolic  acid  or  of  a  bichloride-of- 
mercury  solution  may  be  made  about  the  pustule  and  be 
repeated  two  or  three  times  a  day. 

HYDROPHOBIA. 

Definition  and  Synonym. — Hydrophobia  is  an  acute 
specific  disease  of  animals,  and  is  communicated  to  man  by 
inoculation.     Synonym :  Rabies. 

Etiology. — All  animals  are  susceptible,  but  the  disease  is 
most  common  in  the  dog,  wolf,  cat,  skunk,  and  fox.  There 
is  undoubtedly  a  microbe  of  the  disease,  but  it  has  not  yet 
been  demonstrated.     The  poison   is  found  in  the  nervous 


154        .V.l.vr.lL    OF   THE   rRACriCE    OF  MEDICINE. 

system  and  the  secretions,  especially-  in  tlie  sali\a.  The 
affection  is  acquired  in  man  b\'  bites  of  rabid  animals  or  by 
the  inoculation  of  abraded  surfaces  with  the  saliva.  It 
occurs  more  readil\'  in  chiUlrcn  than  in  adults,  and  infection 
is  most  certain  in  wounds  of  the  face  and  head  and  in  cases 
of  severe  and  lacerated  bites  affording  extensive  surfaces  for 
absorption.  Infection  is  more  severe  in  the  bites  of  wolves 
than  in  those  of  cats  or  dogs.  Of  persons  bitten  by  rabid 
dogs,  from  15  to  50  per  cent.,  according  to  various  author- 
ities, become  affected  by  the  disease.  The  infecting  saliva 
may  be  absorbed  by  the  clothing  if  the  bite  is  inflicted  upon 
a  clothed  part.     In  this  case  infection  may  not  occur. 

The  incubation  period  varies  from  six  weeks  to  two  months 
in  ordinary  cases.  It  may  be  as  short  as  two  weeks,  or  be 
protracted  for  several  months,  but  never  longer  than  eight 
months.  Cases  with  incubation  of  from  one  to  two  years 
have  been   reported,  but   they  are   not  well  authenticated. 

Pathology. — Little  or  no  lesion  may  be  found  at  autopsy. 
Congestion  of  the  blood-vessels,  perivascular  exudation  of 
leucocytes,  and  minute  hemorrhages  may  be  found  in  the 
brain  and  spinal  cord.  These  are  the  most  characteristic 
lesions,  and  are  particularly  well  marked  in  the  medulla. 
There  may  be  congestion  of  the  pharynx  and  of  the  mu- 
cous membrane  of  the  respiratory  and  gastro-intestinal  tract. 

Symptoms. — There  are  three  stages  of  the  disease. 

1.  Premonitory  Stage. — The  onset  is  usually  preceded  by 
irritation,  pain,  or  numbness  in  the  cicatrix,  which  may  be- 
come congested  and  tender.  The  patient  passes  into  a  con- 
dition of  mental  depression  and  melancholia,  becomes  irri- 
table and  sleepless,  and  is  in  a  condition  of  extreme  anxiety. 
The  special  senses  are  keenly  alert.  This  stage  lasts  about 
a  day. 

2.  Spasmodic  Stage. — The  first  characteristic  symptom 
is  inability  to  swallow,  from  spasm  of  the  muscles  of  deglu- 
tition whenever  the  act  is  attempted.  The  spasm  spreads 
to  the  laryngeal  muscles  of  respiration,  causing  dysp- 
noea and  the  utterance  of  odd  barking  sounds.  Breathing 
in  consequence  becomes  painful  and  embarrassed.  The 
spasms,  excited  at  first  by  attempts  at  swallowing,  finally 


HYDRO  PI/OB  LI.  1  =  5 

are  produced  by  any  afferent  stimulant,  such  as  draughts 
of  air,  sounds,  or  even  mental  suggestion,  and  extend  to 
involve  the  muscles  of  the  body  generally.  During  these 
convulsions  the  patient  snaps  with  his  mouth  and  ejects 
foaming  saliva  in  every  direction.  Mania  often  accompanies 
the  spasms,  while  in  the  intervals  the  mind  is  usually  clear, 
though  'distressed  by  fearful  dread  of  impending  death. 
Profuse  salivation  is  common.  The  temperature  is  usually 
elevated,  although  it  may  be  subnormal.  The  pulse  becomes 
increasingly  rapid,  feeble,  and  intermittent.  Prostration  be- 
comes more  marked  after  each  paroxysm.  There  may  be 
death  from  asphyxia  in  any  of  the  paroxysms.  This  stage 
usually  lasts  for  from  one  to  three  days. 

3.  T\\Q  paralytic  stage  \di5is  for  from  six  to  eighteen  hours. 
The  patient  becomes  quiet,  the  spasms  cease,  and  the  patient 
may  swallow  with  ease.  Unconsciousness  is  gradually  de- 
veloped, and  death  from  cardiac  failure  occurs. 

Prog-nosis. — Much  can  be  done  by  preventive  inocula- 
tions in  the  stage  of  incubation.  When  the  disease,  how- 
ever, has  once  begun,  it  is  invariably  fatal. 

Treatment. — Immediately  after  a  person  has  been  bitten 
a  ligature  should  be  applied  on  the  proximal  side,  and  the 
wound  be  sucked  energetically,  provided  there  be  no  cari- 
ous teeth  or  abrasions  of  the  mouth  or  lips  of  the  operator. 
The  best  results  have  followed  an  immediate  excision  of  the 
wound  succeeded  by  thorough  disinfection.  Cauterization 
is  not  so  certain  as  excision  as.  a  method  of  prevention. 

Preventive  Inoculations. — Pasteur  found  that  the  contin- 
uous inoculation  of  the  virus  from  rabbit  to  rabbit  increased 
its  strength  to  a  maximum  virulence,  while  gradual  desic- 
cation of  the  medulla  containing  the  virus  diminished  its 
virulence  so  that  after  two  weeks'  desiccation  the  virus 
became  innocuous.  It  is  possible,  then,  to  obtain  the  virus 
in  any  grade  of  virulence. 

Inoculations  were  made  in  dogs,  beginning  with  injections 
of  an  emulsion  of  the  non-virulent  medulla,  followed  by  those 
of  increasing  strength  until  injections  of  medullas  of  the 
greatest  virulence  could  be  made  with  impunity.  Animals 
so  treated  became  immune  to  hydrophobic  infection. 


156        .V.IXr.lL    OF  THE   PRACTICE    OF  MEDICIXE. 

■  The  same  series  of  injections  are  now  made  in  the  case 
of  those  who  have  been  bitten  b}'  rabid  animals  (altliough 
in  men  the  final  injections  used  are  not  of  the  most  virulent 
qualit)'),  with  the  result  that  the  occurrence  of  h)'drophobia 
in  nearly  all  cases  is  prevented.  The  mortality  of  those 
bitten  by  rabid  animals  and  treated  in  this  manner  has  been 
reduced  to  0.60  per  cent. 

There  is  another  method  of  antirabic  vaccination  proposed 
— the  gradual  inoculation  of  an  innocent  virus  obtained  by 
the  action  of  gastric  juice  upon  the  cords  of  infected  rabbits. 
This  method  has  even  cured  the  developed  disease  in  rab- 
bits, but  it  has  not  yet  been  tried  in  man. 

Treatment  of  tJic  Disease. — When  hydrophobia  develops 
the  spasms  can  be  relieved  only  by  morphine  hypodermics 
and  by  inhalations  of  chloroform.  The  patient  in  this  way 
is  made  more  comfortable  until  he  dies. 

Pseudo-rabies  is  an  hysterical  condition  occurring  in 
persons  who  have  been  bitten  by  dogs  supposedly  rabid, 
and  it  may  closely  simulate  true  hydrophobia.  The  symp- 
toms develop  frequently  too  long  after  the  bite  to  be  real 
rabies ;  the  temperature  is  not  elevated ;  the  disease  is  of 
longer  duration  and  is  amenable  to  antihysterical  treatment. 
The  diagnosis  is  corroborated  by  the  knowledge  of  the  fact 
that  the  dog  was  not  rabid. 

TETANUS. 

Definition  and  Synonyms. — Tetanus  is  an  infectious 
disease  due  to  a  specific   bacillus.     It  is  characterized  by 

painful  tonic  spasms  of  the  volun- 

Q  o^  p  tary   muscles   with    exacerbations. 

I  /  ^  ^-^  Syiioiiyms :   Trismus;   Lock-jaw. 

v^  \  Etiology. — The  bacillus  appears 

^       ^  as  a  delicate  rod  swelling  at  one 

__  ^  extremity    to    contain    a    shining 

Fig.  3.-Baciiius  tetani  (cover-     sporc,  assuming  thus  the  appear- 

glass  preparation   from  culture  by       ^^^^^     ^^    ^     druni-Stick     Or     a     pin. 
Kitasato).  ^ 

Pure  cultures  are  obtained  with 
difficulty.  Injections  of  the  germs,  or  even  of  the  sterilized 
or  filtered  cultures,  cause  tetanus  convulsions.     Brieger  has 


TETANUS.  157 

lately  isolated  from  tetanus  cultures  their  distinct  toxines, 
tetanine,  tetanotoxine,  and  spasmotoxine,  which  act  on  the 
nervous  centres  as  does  strychnine,  causing  convulsions 
and  spasms. 

The  bacilli  are  found  in  various  kinds  of  surface  soil  and 
street  dust.  In  warm  climates  the  soil  acts  as  an  excellent 
culture  medium,  hence  in  these  localities  the  disease  is 
more  common  than  in  colder  climates.  The  bacilli  may 
thrive  in  some  particular  soil  so  that  the  disease  becomes 
endemic  in  that  place,  as  in  the  east  end  of  Long  Island. 
It  may  assume  epidemic  proportions  in  institutions,  in 
hospitals,  and  during  wars.  The  colored  race  is  especially 
susceptible. 

To  acquire  the  disease  the  germ  must  enter  through  an 
abraded  or  a  broken  cutaneous  or  mucous  surface.  It  may 
follow  wounds,  especially  of  the  hands  and  feet,  or  it  may 
infect  the  umbilicus  in  newly-born  children  (tetanus  neona- 
torum). It  frequently  follows  frost-gangrene.  In  some 
cases  the  point  of  entrance  is  so  slight  as  readily  to  be 
overlooked.  These  cases  are  designated  "  idiopathic 
tetanus."  The  majority  of  cases  of  late  have  occurred  in 
children. 

The  bacilli  are  found  in  the  wound-secretions,  in  the 
nerves  leading  from  the  point  of  infection,  and  in  the  spinal 
cord  of  the  patient. 

Pathology. — There  are  no  distinct  morbid  changes. 
There  may  be  seen  congestion,  perivascular  exudation,  and 
granular  degeneration  of  the  nerve-cells  in  the  brain  and 
spinal  cord.  There  may  be  redness  and  swelling  of  the 
nerve-trunks.  In  tetanus  of  the  new-born  there  may  be 
inflammation  of  the  umbilicus. 

Symptoms. — The  period  of  incubation  is  about  two 
weeks,  although  from  one  to  twenty-one  days  constitute  its 
limits.  The  symptoms  begin  insidiously  with  soreness 
about  the  neck  and  pain  and  stiffness  in  the  muscles.  Then 
develops  the  characteristic  spasm  of  the  muscles  of  masti- 
cation. This  trismus,  or  lock-jaw,  is  almost  pathogno- 
monic, provided  local  causes  for  spasm  can  be  excluded. 
The  spasm  then  spreads  to  the  muscles  of  the  back  of  the 


158        .V.iXr.-fL    OF   THE    PRACTICE    OF  .VEDICLVE. 

nock,  of  the  face,  and  of  the  trunk.  The  head  is  drawn 
backward  and  held  rigidl\' ;  the  face  has  a  mask-Hke 
appearance  due  to  immobility;  the  corners  of  the  mouth 
are  drawn  back,  giving  the  "  sardonic  grin."  The  forehead 
is  wrinkled,  the  patient  having  a  peculiarly  aged  appear- 
ance. The  spasm  of  the  spinal  muscles  may  arch  the  body 
backward  so  that  the  patient  is  supported  only  by  the  head 
and  the  heels  (opisthotonos),  and  less  frequently  the  body 
may  be  flexed  forward  (emprosthotonos)  or  curved  to  either 
side  (pleurosthotonos).  In  severe  cases  the  body  is  entirely 
straight  and  stiffened  from  general  muscular  spasm  (or- 
thotonos).  The  legs  may  be  in  a  condition  of  spasm,  but 
the  arms  more  frequently  can  be  moved  freely. 

The  affected  muscles  are  in  a  condition  of  tonic  rigidity 
interrupted  now  and  then  with  violent  clonic  spasms. 
These  spasms  may  be  so  severe  as  to  tear  the  rectus  ab- 
dominalis.  The  muscles  are  exquisitely  painful  and  tender, 
especially  during  a  paroxysm. 

The  paroxysms  are  reflex,  and  are  produced  by  any 
slight  stimulus,  such  as  a  noise,  a  jar,  or  a  draught  of  air. 
In  some  cases  they  may  appear  to  be  spontaneous. 

If  the  intercostal  muscles  are  affected,  there  is  embar- 
rassed respiration  with  dyspnoea  and  cyanosis.  These 
symptoms  are  so  aggravated,  should  the  diaphragm  be 
involved,  that  the  patient  rarely  survives  the  second  or 
third  tetanic  spasm. 

In  rare  cases  the  muscles  of  deglutition  are  involved.  These 
cases  are  spoken  of  as  "  hydrophobic  tetanus  "  or  the  "  head- 
tetanus  "  of  Rose,  and  follow  injury  of  the  face.  Besides  the 
trismus  and  the  difficult  deglutition  there  is  apt  to  be  paral- 
ysis of  the  facial  nerve  on  the  side  of  the  injury. 

The  temperature  is  always  elevated  in  acute  cases,  usually 
running  to  104°  F.  or  even  higher.  There  may  be  a  marked 
rise  of  temperature  after  death.  In  the  milder  and  more 
chronic  cases  there  may  be  but  slight  fever  or  the  tempera- 
ture may  be  normal.  The  pulse  becomes  rapid  and  feeble 
toward  the  close  of  the  disease.  The  mind  is  clear  through- 
out.    There  is  usually  profuse  perspiration. 

The  duration  v^aries.     The  acute  forms  may  be  fatal  in 


TETANUS.  159 

from  one  to  seven  days.  If  the  attack  be  mild,  there  may- 
be but  Httle  spasm  of  the  muscles  of  the  trunk,  and  consti- 
tutional disturbances  are  not  marked.  In  these  cases  tris- 
mus is  the  principal  symptom.  These  mild  cases  run  a 
course  for  a  number  of  weeks. 

Diagnosis. — Tetanus  should  not  be  confounded  with  the 
following  conditions  : 

1.  Stryclinine-poisoiiing. — Here  the  maximum  symptoms 
are  developed  suddenly,  the  muscles  not  being  involved  in 
gradual  order  as  in  tetanus.  Trismus  is  absent  and  the 
arms  are  involved.  Between  the  spasms  the  muscles  are 
relaxed,  and  not  rigid  as  in  tetanus.  The  course  is  shorter 
than  that  of  tetanus. 

2.  HydropJiobia. — Here  there  are  the  history  of  the  case, 
involvement  chiefly  of  the  muscles  of  deglutition,  and 
absence  of  trismus. 

3.  Hysteria. — The  convulsions  are  not  limited  to  any 
special  group  of  muscles ;  there  is  no  trismus ;  between  the 
spasms  there  is  muscular  relaxation ;  there  is  no  change  in 
temperature  or  pulse ;  other  hysterical  symptoms  are  pres- 
ent ;  the  spasms  are  irregular  and  more  spontaneous  than 
reflex. 

Prognosis. — The  disease  is  fatal  in  80  per  cent,  of  trau- 
matic cases  and  in  50  per  cent,  of  idiopathic  cases.  It  is 
almost  always  fatal  in  infants.  Most  of  the  cases  of  hydro- 
phobic tetanus  recover.  When  the  incubation  period  is  less 
than  ten  days,  the  mortality  is  96.6  per  cent. 

Treatment. — The  patient  should  be  kept  in  a  darkened 
room  from  which  all  sounds  and  other  causes  of  irritation 
are  to  be  excluded  absolutely.  No  talking  or  unnecessary 
movements  are  to  be  permitted.  If  the  trismus  prevents 
the  patient  from  taking  even  fluid  food,  he  may  be  fed 
through  a  tube  or  by  the  rectum.  To  relieve  the  spasms 
morphine  hypodermically  is  the  most  satisfactory  drug. 
In  milder  cases  chloral  combined  with  sodium  bromide  may 
be  employed.  In  very  severe  cases  inhalations  of  chloroform 
may  be  necessary.  In  mild  cases  the  use  of  hot  baths  may 
be  of  service.  Woorara,  which  has  been  employed  fre- 
quently,  is    not   recommended,   because   of  its   depressing 


l6o        MAXrAL    OF   THE   PRACTICE    OF  MEDICEYE. 

effect  on  the  heart.  In  all  cases  the  infected  wound  must 
be  disinfected  to  prevent  further  absorption.  Scars  may  be 
excised  and  foreii^n  bodies  be  removed.  Nerve-stretching 
and  nerve-section  have  proved  disappointing. 

The  hope  of  successful  treatment  lies  in  the  use  of  anti- 
toxines  derived  from  the  blood-serum  of  animals  rendered 
immune.  Immunity  is  procured  by  the  injection  of  germ 
cultures  treated  with  trichloride  of  iodine.  The  injection 
of  the  blood-serum  of  such  immune  animals  into  persons 
suffering  from  tetanus  has  frequently  been  followed  by  a 
prompt  recovery,  while  in  almost  all  cases  the  severity  of 
the  disease  has  been  modified  greatly. 

In  severe  cases  the  patient  may  be  trephined  and  the 
antitoxine  injected  directly  into  the  brain. 

Bacelli's  treatment  consists  in  the  hypodermic  injection 
of  oj-ij  of  a  ^  per  cent,  solution  of  carbolic  acid  along  the 
spinal  column  every  three  or  four  hours. 

LEPROSY. 

Definition. — Leprosy  is  a  chronic  infectious  disease  due 
to  the  bacillus  leprse  and  characterized  by  tubercular 
nodules  of  the  skin  and  the  mucous  membranes  and  by 
changes  in  the  nerves. 

Etiolog-y. — At  present  the  principal  centres  of  leprosy 
are  India,  China,  and  the  Sandwich  Islands.  Other  import- 
ant foci  are  Norway,  the  Baltic  provinces  of  Russia, 
Mexico,  certain  parts  of  Central  and  South  America,  and 
the  West  India  Islands.  In  North  America  it  occurs  in 
certain  of  the  Gulf  cities,  especially  New  Orleans,  in  the 
province  of  New  Brunswick,  and  along  the  Pacific  coast, 
where  it  occurs  chiefly  among  the  Chinese.  Isolated  cases 
occur  from  time  to  time  in  all  large  cities. 

The  disease  may  be  called  "  contagious,"  but  only  in  the 
sense  that  direct  inoculations  are  necessary,  as  is  the  case 
with  syphilis.  It  may  be  congenital  or  hereditary,  and  it 
may  be  acquired  through  sexual  congress.  The  majority 
of  cases  occur  from  the  fifteenth  to  the  thirtieth  year.  The 
specific  cause  is  the  bacillus  lepr£e,  discovered  in  1874  by 
Hansen.       This    bacillus,    which    closely    resembles    the 


LEPROSY.  l6l 

tubercle  bacillus  but  may  be  distinguished  from  it,  can  be 
cultivated;  but  while  inoculations  of  the  leprous  nodules 
can  reproduce  the  disease,  inoculations  of  the  pure  bacillus 
cultures  have  produced  only  negative  results. 

Patholog-y. — The  leprous  nodules  consist  of  aggregated 
lymphoid,  epithelioid,  and  giant  cells  in  and  among  which 
are  found  numerous  bacilli.  The  nodules  may  in  rare  cases 
become  organized  and  encapsulated,  but  they  have  a  tend- 
ency to  break  down,  discharge  puriform  matter,  and  result 
in  ulcers  which  may  heal  in  one  direction  while  spreading 
in  another.  In  the  nerves  the  bacilli  cause  neuritis.  In  the 
last  stages  of  the  disease  leprous  nodules  may  be  found  in 
internal  organs,  especially  the  spleen  and  the  liver. 

Symptoms. — Two  forms  are  described,  which  may 
occur  separately  or  be  combined  in  the  same  patient  : 

1.  Tubercular  Leprosy. — There  appear  on  the  skin  hyper- 
aesthetic  patches  of  sharply-defined  erythema  that  become 
gradually  darker  from  pigmentation.  These  patches  which 
precede  the  nodules  are  designated  as  "  macular  leprosy." 
In  some  cases  they  subsequently  become  anaesthetic  and 
lose  their  pigment,  white  spots  being  left,  the  "  white 
leprosy."  Nodules  then  develop  in  the  skin  of  any  part  of 
the  body  excepting  the  scalp,  and  in  the  mucous  mem- 
branes, especially  of  the  mouth,  throat,  larynx,  and  con- 
junctiva. The  nodules  vary  in  size  from  a  pea  to  a  walnut, 
and  coalesce.  This  is  especially  marked  in  the  face,  the 
term  leontiasis  being  applied  to  the  thickened  and  distorted 
features  so  caused. 

The  skin  over  the  nodules  is  tense  and  glistening  and 
may  become  red  and  painful.  The  hairs  of  the  affected 
areas  drop  out,  the  loss  of  the  eyebrows  being  a  suggestive 
symptom.  From  the  softening  and  breaking  down  of  the 
nodules  there  are  caused  extensive  ulcerations  frequently 
covered  with  crusts.  The  ulceration  may  extend  to  the 
bones,  causing  falling  of  the  bridge  of  the  nose  or  loss  of 
the  fingers  or  toes,  or  there  may  be  total  destruction  of  the 
eyeball. 

2.  AiicestJictic  leprosy  occurs  when  the  nerve-trunks  are 
involved.      There  are  at  first  areas  of  hypersesthesia  and 

11 


l62        .V.LVC.IL    OF   THE   rKAC'lICE    OF  MEDICIXE 

neuralgic  pains,  followed  by  anaesthesia  over  more  or  less 
extensive  surfaces.  The  an;esthetic  spots  following  the 
macules  have  already  been  alluded  to.  If  the  larger  nerve- 
trunks  are  involved,  they  may  be  felt  as  nodular  cords. 
Suppression  of  sweating  occurs  in  the  affected  areas. 

There  are  trophic  changes.  Bulhie  may  form  at  any  time, 
and  after  discharging  their  contents  may  either  heal  or  be 
converted  to  extensive  ulcers.  There  may  be  perforating 
ulcer  of  the  foot  or  loss  of  the  phalanges  of  the  fingers  or 
the  toes.  Paralyses,  contractures,  and  atrophy  of  muscles 
are  commonly  observed. 

The  prognosis  is  bad,  but  not  absolutel}'  hopeless.  The 
average  duration  of  the  tubercular  cases  is  from  eight  to 
ten  years  ;  of  the  anaesthetic  cases,  fifteen  to  twenty  years. 

Treatment. — Patients  should  li\e  in  isolated  communities 
and  under  the  best  hygiene.  Their  general  health  and  nutri- 
tion must  be  superintended  carefully. 

There  is  no  specific  medication.  Iodide  of  potassium  in 
full  doses  (falling  short,  however,  of  iodism)  and  arsenic 
have  been  recommended.  Of  late  gurjun  oil  in  lO-minim 
doses  and  chaulmoogra  oil  in  2-dram  doses  have  been 
favorably  regarded.  The  former  may  be  given  by  the 
mouth  or  by  inunction. 

GLANDERS. 

Definition  and  Synonym. — Glanders  is  an  infectious 
disease  of  the  horse,  ass,  and  mule,  communicable  to  man. 
Synonym  :  Farcy. 

Etiology. — The  disease  is  due  to  a  specific  bacillus,  the 
bacillus  mallei,  which  is  short  and  non-motile,  closely 
resembling  the  tubercle  bacillus.  The  bacillus  can  be 
cultivated,  and  causes  the  disease  by  inoculation.  The 
disease  is  acquired  in  man  by  contact  of  the  nasal  dis- 
charges of  the  horse  with  an  abraded  mucous  or  cutaneous 
surface.  In  rare  cases  it  results  from  inhalation  of  the 
desiccated  discharges.  The  disease  is  also  transmissible 
from  man  to  man.  It  occurs  chiefly  in  those  who  have  to 
do  with  horses. 

Lesion. — The  lesion   consists   in  the  formation   of  little 


GLANDERS.  1 63 

tumors  composed  of  epithelioid  and  lymphoid  cells  among 
and  in  which  are  found  the  bacilli.  The  lesion  is  really  a 
variety  of  infective  granuloma.  The  nodules  tend  to 
break  down  rapidly,  causing  ulcers  when  they  occur  in  the 
mucous  membranes  (glanders),  and  abscesses  when  they 
occur  in  the  skin,  the  muscles,  or  the  internal  viscera.  The 
adjacent  skin,  lymphatics,  and  mucous  membrane  are 
inflamed. 

Symptoms. — The  symptoms  begin  in  from  three  to  five 
days  after  inoculation,  but  may  be  delayed  for  three  weeks. 
An  acute  and  a  chronic  form  may  be  recognized  in  man. 

I.  Acute  Glanders. — There  are  at  the  onset  malaise,  head- 
ache, fever,  and  pain  in  the  limbs,  resembling  the  onset  of 
typhoid  fever,  for  which  it  is  often  mistaken.  In  peracute 
cases  the  onset  is  that  of  a  more  severe  general  infection. 
The  local  symptoms  may  be  of  the  "  farcy "  or  of  the 
"  glanders  "  type. 

Farcy  Type. — The  infected  part  becomes  red,  swollen, 
and  painful,  the  inflammation  becoming  widely  diffused ; 
there  are  developed  nodules  which  become  abscesses.  These 
latter  may  rupture,  leaving  irregular  deep  ulcers  with  a 
grayish  infiltrated  floor  which  may  become  necrotic.  These 
suppurating  nodules  are  frequently  mistaken  for  small-pox. 
The  lymphatics  are  early  affected,  and  along  their  course 
are  subcutaneous  nodules,  the  so-called  "  farcy-buds." 
There  may  be  swelling  and  suppuration  of  the  joints. 
Abscesses  may  form  in  the  muscles. 

Glanders  Type. — There  is  a  purulent,  blood-stained,  fetid 
discharge  from  the  nose,  with  a  spreading  inflammation  of 
the  skin  over  the  nose  and  the  face  somewhat  resembling 
erysipelas.  Examination  shows  the  nasal  cavities  to  be 
deeply  ulcerated.  The  septum  may  be  necrosed.  There 
may  be  similar  ulcerations  in  the  mouth,  pharynx,  larynx, 
and  bronchi.  Usually  in  man  both  sets  of  local  symptoms 
are  found. 

Constitutional  symptoms  are  those  of  an  intense  infection. 
The  temperature  rises  and  may  assume  the  pyaemic  type, 
with  remissions  and  irregular  rises  accompanied  by  chills 
and  sweating.     The  pulse  becomes  rapid  and  steady,  the 


164        .V.l.VC'.lL    OF   THE    PRACrrCE    OF  MEDIC /XE. 

tongue  brow  n  and  ilr\'.  Vomiting  and  diarrhoea  are  almost 
constant.  Pneumonia  is  apt  to  develop.  There  are  restless- 
ness and  delirium  at  first,  passing  into  stupor  and  coma, 
while  death  results  in  the  t\'phoid  contlition  in  from  eight  to 
fourteen  days.  IVracute  cases  may  live  but  a  few  days.  In 
mild  cases  the  local  symptoms  are  less  severe  and  the  gen- 
eral infection  is  slight  and  limited,  so  that  the  course  is  mild 
and  recovery  is  possible.  The  cases  in  which  the  nose  is 
extensively  involved — glanders  type — are  invariably  severe 
and  fatal. 

2.  Chronic  Glanders. — The  disease  is  insidious,  resembling 
ozasna  or  nasal  s}'philis.  There  is  a  fetid,  purulent  discharge 
from  the  nose,  with  intractable  ulcerations.  There  are  also 
subcutaneous  nodules,  abscesses,  and  ulcers  without  much 
inflammatory  reaction  or  involvement  of  the  lymphatics. 
These  cases  may  last  for  months  or  even  years,  and  usually 
recover,  although  at  any  time  the  acute  form  may  be  de- 
veloped with  a  fatal  issue. 

Treatment. — In  the  early  stages  the  wound  should  be 
excised  or  cauterized  and  treated  antiseptically.  For  the 
acute  cases  little  can  be  done.  The  nasal  passages  should 
be  kept  cleansed  by  injections  of  weak  antiseptic  solutions. 
Abscesses  and  farcy-buds  should  be  opened  as  early  as 
possible. 


ACTINOMYCOSIS. 

Definition. — Actinomycosis  is  a  form  of  chronic  inflam- 
mation caused  by  the  actinomyces,  or  ray  fungus. 

Etiology. — Actinomycosis  is  a  disease  primarily  of  cattle^ 
pigs,  or  horses,  acquired  in  man  by  inoculations  through 
abrasions  of  the  skin,  of  the  mucous  membrane  of  the  mouth, 
or  through  carious  teeth.  The  fungus  may  be  taken  into 
the  alimentary  canal  in  contaminated  water,  in  the  flesh  of 
the  pig,  or  in  infected  cereals. 

The  ray  fungus,  or  actinomyces,  consists  of  threads  with 
bulbous  extremities  radiating  from  a  common  centre,  form- 
ing a  globular  rosette.  In  man  the  fungi  appear  as  little 
round  masses  the  size  of  a  millet-seed,  usually  of  a  sulphur- 


ACT f NO. MYCOSIS. 


165 


yellow   color.     They  are   found   in   the   tumors  and  in  the 
purulent  discharges,  and  can  be  cultivated  and  inoculated. 

Patholog-y. — The  lesion  consists  in  the  transformation 
of  mature  connective  tissue  into  embryonal  or  granulation- 
tissue  composed  of  round  and  epithelioid  cells  sometimes 
containing  giant-cells.  The  appearances  are  identical  with 
those  of  sarcoma  or  tubercle,  but  in  the  tumors  the  cha- 
racteristic ray  fungus  is  found.     The  tumors  show  a  tend- 


Fig.  4. — Actinomyces  (Von  Jaksch). 


ency  to  break  down  and  suppurate,  forming  abscesses  and 
sinuous  fistulse.  There  is  a  chronic  inflammation  of 
the  sCirrounding  structures,  but  the  lymphatics  are  not 
involved,  and  the  course  of  the  disease  resembles  that 
of  a  malignant  tumor  more  than  that  of  an  acute 
infection. 

Symptoms. —  i.  Alimentary  Actinomycosis. — The  upper  or 
lower  jaw  is  frequently  involved.  There  is  considerable 
swelling  and  enlargement  of  the  bone  resembling  osteo- 
sarcoma ;  sinuses  are  common,  tending  to  invade  the  ad- 
jacent soft  structures  of  the  neck  and  the  face.  The  tongue, 
the  intestines,  or  the  liver  may  be  involved  primarily  or  by 
metastasis. 

2.  Cutaneous  Actinomycosis. — There  may  be  slowly-grow- 
ing tumors  which  may  suppurate  and  leave  intractable  ulcers 
and  fistulous  tracts. 

3.  Cerebral  Actinomycosis. — This  form  is  rare.  The  symp- 
toms are  those  of  multiple  tumors  or  abscesses. 

4.  Pulmonaiy  Actinomycosis. — Three    clinical    forms    are 


l66        .U.IXC.IL    OF   THE    PKALTICE    OF  MED/C/XE. 

described  by  Hodenpyl :  {<i)  There  may  be  the  lesions  of 
chronic  bronchitis  with  the  actinomyces  in  the  sputum.  (/;) 
Small  nodules  may  be  scattered  in  the  lungs,  resembling 
miliary  tuberculosis,  (r)  The  lesions  \w:\y  be  more  exten- 
sive— broncho-pneumonia,  interstitial  pneumonia,  large  ab- 
scesses. In  some  cases  there  may  be  abscesses  of  the  chest- 
wall  that  may  be  mistaken  for  empyema. 

The  prognosis  is  good  if  the  disease  be  recognized  early 
and  if  the  infected  locality  be  amenable  io  surgical  treat- 
ment. Spontaneous  recovery  does  not  occur.  The  prog- 
nosis of  internal  actinomycosis  is  bad. 

Treatment  is  entirely  surgical,  consisting  in  the  excision 
or  cauterization  of  the  diseased  masses  and  in  opening  and 
disinfecting  abscesses  and  sinuses.  Injections  of  weak  anti- 
septics into  diseased  internal  tissues  may  be  made. 

MILK    SICKNESS. 

This  disease  occurs  west  of  the  Alleghany  Mountains  and 
is  associated  with  the  "  trembles  "  in  cattle.  It  is  communi- 
cated to  man  by  infected  meat  or  milk,  also  by  butter  and 
cheese.  The  animals  subject  to  the  disease  are. cattle,  lambs, 
and  colts.  The  disease  is  most  frequent  in  new  settlements, 
and  with  the  advance  in  civilization  is  rapidly  becoming 
extinct. 

The  pathology  is  unknown. 

The  symptoms  in  cattle  are  refusal  of  all  food,  in- 
jected eyes,  marked  tremors  or  "  trembles,"  and  death  in 
convulsions. 

The  symptoms  in  man  begin  with  abdominal  pain,  nau- 
sea, and  vomiting.  There  is  intense  thirst  with  fever.  The 
breath  becomes  peculiarly  offensive.  The  tongue  is  swollen 
and  tremulous.  Cerebral  symptoms  develop — restlessness, 
delirium,  and  coma;  the  patient  passes  into  the  typhoid 
state  and  dies.  Acute  cases  last  for  two  or  three  days; 
subacute  cases  continue  for  two  or  three  weeks. 

The  treatment  is  entirely  symptomatic. 


BUBONIC  PLAGUE.  .  1 6/ 

WEIL'S   DISEASE. 

This  disease  was  first  described  in  1886  by  Weil,  and 
bears  his  name.  The  exact  nature  of  the  disease  is  un- 
known. It  is  most  common  in  the  summer  months,  when 
small  epidemics  may  appear.  It  attacks  males  in  90  per  cent, 
of  the  cases,  is  most  common  between  the  ages  of  twenty- 
five  and  forty,  and  butchers  seem  especially  liable  to  it. 

Symptoms. — The  onset  is  acute,  being  marked  by  head- 
ache, by  pain  in  the  back  and  muscles,  and  by  fever  which 
is  usually  of  a  pronounced  remittent  type.  Jaundice  appears 
early  and  is  of  the  obstructive  form,  with  clay-colored  stools. 
The  liver  and  spleen  are  swollen,  and  the  liver  is  tender  on 
palpation.  Albuminuria  is  commonly  observed.  Gastro- 
intestinal symptoms  are  but  rarely  observed.  Cerebral 
symptoms  may  appear  in  severe  cases.  The  duration  of  the 
disease  is  from  ten  to  fourteen  days.  A  definite  relapse 
occurs  from  the  third  to  the  eighth  day  in  40  per  cent,  of 
cases. 

Prog-nosis  is  good. 

Treatment  is  symptomatic. 

BUBONIC    PLAGUE. 

Etiolog-y. — The  cause  of  the  disease  is  infection  by  a 
specific  bacillus  discovered  by  Kitosato  in  1894.  The 
bacillus  is  a  small  non-motile  tod  with  rounded  extremities, 
showing  well-marked  polar  staining,  and  varying  much  in 
its  form.  It  does  not  possess  great  vitality,  as  it  dies  in 
linen,  wool,  and  earth  within  eight  days.  The  germ  ad- 
heres obstinately  to  human  habitations,  and  develops  espe- 
cially amid  squalid  surroundings.  Rats  are  especially 
subject  to  the  disease,  and  are  infected  either  by  eating 
food  covered  by  plague-dust  or  the  bodies  of  dead  infected 
rats. 

Symptoms. — The  germ  may  obtain  entrance  to  the  body 
through  the  skin  or  through  inspired  air.  Primary  infection 
of  the  tonsils  has  occurred.  The  entrance  through  the  skin 
is  the  usual  form,  and  from  the  symptoms  induced  the  de- 
scriptive term  "  bubonic  "  has  been  appHed.     The  lymph- 


l68        MA.Vi'AL    OF   TJIF.    rRACTlCE    OF  MEDICINE. 

glands  nearest  the  point  of  infection  swell  and  usually  sup- 
purate. .  Associated  lymphangitis  is  commonly  observed. 
If  the  gland  filter  is  broken  through,  a  plague-septicaemia 
results,  which  terminates  fatally.  At  the  onset  the  tem- 
perature rises  to  I02°-I05°  F.,  with  marked  exhaustion. 
An  extreme  apathy  and  indifference  to  surroundings  is  ex- 
ceedingly characteristic.  The  tongue  is  moist  and  covered 
with  a  whitish  fur  like  mother-of-pearl.  Glandular  swelling 
becomes  noticed  within  a  few  hours,  the  groin,  axilla,  or 
neck  being  the  favorite  situations.  By  the  second  or  third 
day  the  glandular  symptoms  are  fully  developed;  there  may 
be  suppuration  or  gangrene.  Hemorrhages  may  occur. 
Death  usually  results  on  the  fourth  day.  If  life  be  pro- 
longed longer  than  this  the  patient's  chances  for  recovery 
are  fairly  good. 

When  infection  occurs  through  the  lungs,  glandular  symp- 
toms are  not  observed.  The  disease  then  develops  like  an 
acute  influenza,  with  chill,  fever,  cough,  and  rusty  sputum 
containing  the  bacilli.  The  process  in  the  lungs  is  one  of 
broncho-pneumonia,  the  physical  signs  are  not  always  clear, 
and  death  usually  results  from  acute  septicaemia. 

Prognosis  is  bad  ;  the  death-rate  among  the  Chinese  and 
natives  of  India  being  90  per  cent,  and  over.  Among 
Europeans  it  is   50  per  cent. 

Treatment. — The  prophylactic  treatment  consists  of  the 
disinfection  of  all  products  of  the  disease  containing  the 
bacilli.  Especial  care  should  be  taken  to  disinfect  houses, 
ships,  etc.,  that  contain  rats.  Haffkine's  prophylactic  in- 
oculations should  be  employed  on  all  exposed  persons,  the 
fluid  being  a  devitalized  solution  of  plague-bacilli. 


n.    DISEASES  OF  THE  CIRCULATORY 
SYSTEM. 


L  DISEASES  OF  THE  PERICARDIUM. 

The  diseases  of  the  pericardium  may  be  described  ana- 
tomically and  clinical!}'  under  the  following  divisions  :  i. 
Acute  plastic  or  dry  pericarditis ;  2.  Pericarditis  with  effu- 
sion ;  3.  Purulent  pericarditis,  or  empyema  of  the  pericar- 
dium;  4.  Chronic  adhesive  pericarditis;  5.  Tubercular  peri- 
carditis ;  6.  Cancerous  pericarditis. 

Dry  pericarditis  and  pericarditis  with  effusion  may  be 
considered  together  under  the  general  heading  of 

PERICARDITIS. 

Etiology. — Pericarditis  is  due  to "  infective  processes  or 
to  the  extension  of  inflammation  from  contiguous  organs. 

Primary  or  idiopathic  cases  are  rare  except  as  the  result 
of  traumatism  either  external  or  from  within,  as  by  the 
passage  of  a  foreign  body  through  the  oesophagus  to  the 
pericardium. 

Secondary  inflammation  is  common,  from  the  following 
causes : 

{a)  Pericarditis  from  extension  may  complicate  various 
diseases  of  the  lung  or  the  pleura,  such  as  pneumonia, 
pleurisy,  tubercular  disease,  or  cancer.  In  double  pleurisy 
the  pericardium  is  usually  involved.  The  disease  may 
result  from  the  extension  of  inflammation  of  the  abdominal 
organs,  such  as  peritonitis  or  abscess  of  the  liver  ;  it  may 
also  result  from  inflammation  of  the  heart-wall,  as  in 
myocarditis. 

{h)  Pericarditis  is  one  of  the  most  important  complica- 
tions of  rheumatism,  occurring  in  from  14  to  37  per  cent, 
of  all  cases  of  the  latter  disease.  The  disease  may  occur 
with  either  mild  or  severe  forms,  may  precede  the  articular 
affections,  and  often  occurs  in  the  abarticular  forms  of 
rheumatism  in  children. 

169 


l-O        .UAXCAL    OF   THE   rRACTICK    OF  MEDIC /.VE. 

(f)  Pericarditis  may  accompari}'  any  of  the  eruptive 
fevers,  especially  scarlatina. 

{d)  The  disease  may  complicate  any  of  the  septic 
diseases,  as  pw-emia,  puerperal  fever,  malignant  endocar- 
ditis, septic  thrombi,  gonorrhoea,  bone  necrosis,  or  in- 
fluenza.    It  is  not  infrequent   in  pneumonia. 

{c)  Certain  dyscrasias  render  the  pericardium  susceptible 
to  inflammation.  Gouty,  scorbutic,  and  diabetic  patients 
are  liable  to  pericarditis,  while  with  Bright's  disease  peri- 
carditis is  b\'  no  means  rare,  especially  in  patients  over  fifty 
years  of  age. 

Pericarditis  occurs  at  all  ages,  but  is  more  common  in 
}-oung  adults.  It  may  be  a  disease  of  intra-uterinc  life,  or 
it  may  occur  in  the  newh--born  from  septic  infection 
through  the  navel.  In  childhood  pericarditis  is  more 
commonly  due  to  rheumatism  or  scarlet  fever,  while  in 
advanced  life  it  is  oftenest  associated  with  the  atrophic  form 
of  Bright's  disease. 

The  lesion  of  pericarditis  resembles  that  of  the  kindred 
inflammations  of  the  pleura  in  which  the  inflammation  may 
be  plastic  with  but  a  small  amount  of  effusion,  or  ma)'  pass 
into  the  stage  in  which  effusion  is  abundant  and  alters  the 
clinical  course  and  the  physical  signs  of  the  disease.  The 
inflammatory  process,  however,  is  the  same,  differing  only  in 
the  amount  of  serum  exuded. 

The  lesion  may  be  localized  or  general  at  the  start.  The 
base  and  the  anterior  surface  of  the  heart  are  oftenest 
affected.  The  pericardium  becomes  dry,  congested,  lustre- 
less, and  covered  with  an  exudate  of  fibrin  in  the  meshes 
of  which  a  certain  amount  of  fluid  effusion  is  entangled. 
The  fibrin  may  be  thin  and  dry  like  a  membrane,  under 
which  the  pericardium  appears  congested,  or  it  may  be  in 
long  shreds,  giving  a  hairy  appearance  to  the  heart — the 
cor  villosiu)i ;  or,  if  the  fibrin  is  abundant,  the  pericardium 
may  have  a  ridge-like  appearance  resembling  buttered  sur- 
faces of  bread  drawn  apart — the  "  bread-and-butter  pericar- 
dium." This  is  the  lesion  of  plastic  pericarditis.  Pericar- 
ditis with  effusion  does  not  stop  here,  but  an  exudate  of 
serum  containing  desquamated  and  proliferated  endothelial 


rERICA  RD/7VS.  1 7 1 

cells,  scanty  pus-corpuscles,  and  flocculi  of  fibrin  is  poured 
out  to  an  amount  varying  from  200  cubic  centimeters  to  2 
liters.  The  serum  may  be  admixed  with  blood  in  old  and 
cachectic  patients.  This  effusion  fills  the  pericardial  sac, 
displaces  the  heart  upward  and  to  the  left,  and  may  be 
abundant  enough  to  exert  pressure  on  the  heart,  especially 
the  auricles  and  the  venae  cavjE,  the  left  bronchus,  the 
oesophagus,  and  the  lung,  or  to  exert  traction  on  the  recur- 
rent laryngeal  nerve. 

In  mild  cases  the  myocardium  is  turbid  and  pale  to  the 
depth  of  from  2  to  3  millimeters,  but  in  more  severe  cases 
the  myocarditis  is  more  extensive  and  may  endanger  the  life 
of  the  patient.  Pericarditis  is  often  associated  with  endo- 
carditis, as  both  diseases  are  apt  to  arise  from  the  same 
causes.  In  rare  cases  inflammation  may  spread  from  the 
one  to  the  other  membrane. 

Pericarditis  may  terminate  in  the  following  ways:  (i)  By 
resolution  and  absorption  of  both  fibrinous  and  serous  exu- 
date. (2)  By  organization  of  the  fibrin  into  connective-tis- 
sue adhesions.  From  such  an  adherent  pericardium  may 
result  hypertrophy  and  dilatation  of  the  heart,  often  to  an 
extreme  degree,  chronic  interstitial  myocarditis,  and  fatty 
degeneration  of  the  heart.  (3)  The  inflammation  may  be- 
come chronic.  The  pericardium  becomes  thickened  by  con- 
nective-tissue growth  and  may  be  infiltrated  with  salts  of 
lime,  and  the  fluid  may  not  be  absorbed.  This  condition  is 
especially  seen,  however,  in  tubercular  cases. 

The  symptoms  may  be  divided  into  four  groups : 

I.  Inflmmnatory  Symptoms. — An  initial  chill  is  rare. 
Fever  is  not  usually  high  ;  it  may  be  irregular  or  absent. 
Hyperpyrexia  has  been  observed  in  rheumatic  cases.  Pain, 
which  is  noted  in  about  three-quarters  of  all  the  cases,  may 
be  distressing  and  intense,  resembling  angina,  or  the  patient 
may  complain  only  of  a  feeling  of  uneasiness,  may  be,  or 
oppression.  The  pain  may  be  referred  to  the  precordia  or 
to  the  lower  part  of  the  sternum.  The  pain  usually  dimin- 
ishes as  fluid  accumulates,  but  in  some  cases  it  becomes 
thereby  increased.  It  may  be  increased  when  the  patient 
inclines  forward  or  when  pressure  is  exerted  upward  from 


172        M.-iXCAL    OF   THE    PRACTICE    OF  MEDIChXE. 

the  epigastrium.  There  may  be  tenderness  on  pressure 
over  the  precordia.  These  inflammatory  symptoms  may  be 
slight,  the  onset  of  the  disease  being  insidious.  There  may 
be  only  a  gradual  failing  in  health,  slight  dyspnoea,  and  in- 
creasing pallor. 

2.  Deranged  action  of  the  heart  is  seen  in  both  forms  of 
pericarditis,  and  depends  upon  the  associated  nn-ocarditis. 
If  there  be  no  myocarditis,  the  pulse  may  be  rapid  and  irreg- 
ular or  strong  and  tumultuous.  In  dry  pericarditis  of  a 
small  area  the  pulse  may  be  but  slightly  altered.  If  nu'o- 
carditis  be  extensive,  the  power  of  the  heart  is  thereby 
weakened  and  symptoms  of  heart  failure  ensue.  The  pulse 
becomes  rapid,  feeble,  and  irregular ;  the  patient  feels  faint 
and  complains  of  dyspnoea.  In  bad  cases  there  may  even 
be  venous  congestions,  especially  if  the  venae  cavae  be  pressed 
upon  by  the  distended  pericardial  sac.  The  presence  of 
venous  congestions  is  almost  a  proof  of  the  presence  of 
myocarditis  or  complicating  endocarditis. 

3.  Pressjtre-symptoins  occur  with  abundant  effusion.  The 
heart's  action  becomes  irregular  and  weak  ;  the  veins  of  the 
neck  and  the  arm  may  become  congested  and  enlarged. 
Dyspnoea  may  be  aggravated  by  pressure  on  the  left  bron- 
chus. Pressure  or  traction  on  the  recurrent  laryngeal  nerve 
as  it  winds  around  the  aorta  will  produce  hoarseness  or 
aphonia,  laryngeal  cough,  and  dyspnoea  which  may  be  spas- 
modic and  distressing.  With  large  pericardial  effusions 
may  be  observed  the  pulsus  paradoxus,  in  which  the  pulse- 
wave  is  weak  or  even  imperceptible  during  inspiration. 

4.  Syinptoms  of  the  primary  disease  often  coexist  with 
those  of  the  pericarditis,  and  may  obscure  the  diagnosis. 
To  be  on  the  safe  side,  the  temperature  and  the  pulse  should 
be  recorded  in  every  disease  that  may  cause  pericarditis, 
especially  rheumatism  and  scarlet  fever,  even  into  convales- 
cence, and  physical  examinations  of  the  heart  should  be 
made  regularly.  There  should  be  special  inquiry  as  to 
pain  and  dyspnoea.  Pericarditis  should  be  suspected  in 
every  case  of  Bright's  disease  seriousl}^  sick  with  obscure 
symptoms. 

Physical  Signs. — Palpation  may  reveal  a  friction  fremitus 


rERrcAKDir/s. 


173 


best  marked  over  the  right  ventricle.  The  characteristic 
sign  is  the  friction  sound.  It  is  of  a  rubbing,  grating,  or 
sticky  quaUty,  and  may  in  some  cases  resemble  the  creak- 
ing of  new  leather.  It  may  occur  during  the  systole,  dur- 
ing the  diastole,  or  during  both,  the  last  being  the  most 
common.  In  rare  instances  it  has  a  triple  rhythm.  It  is 
not  exactly  synchronous  with  the  heart  sounds,  the  double 
or  to-and-fro  movement  usually  outlasting  the  first  and 
second  sounds.  The  friction  sound  appears  superficial  close 
to  the  ear  and  is  intensified  by  pressure  with  the  stetho- 
scope or  by  inclining  the  patient  forward.  It  is  heard 
best  over  the  exposed  portions  of  the  heart — that  is,  in  the 
fourth  and  fifth  spaces  near  the  sternum*  It  may,  however, 
be  heard  at  the  extreme  base 
or  apex.  It  is  not  trans- 
mitted in  any  direction,  as 
are  endocardial  murmurs. 
The  friction  sound  is  incon- 
stant, coming  and  going  with- 
out apparent  cause,  and  it 
suffers  frequent  changes  in 
character  and  point  of  maxi- 
mum intensity. 

In  cases  with  effusion  the 
friction  rale  may  disappear 
as  the  pericardial  surfaces  are 
separated,  or  the  rale  may  be 
heard  at  the  upper  part  of  the 
heart.  It  reappears  with  the 
absorption  of'  the  fluid.  On 
inspection  there  may  be 
bulging  of  the  precordia,  especially  in  children.  The 
antero-lateral  region  of  the  chest  may  even  be  enlarged. 
Bulging  of  the  precordia  without  visible  pulsation  is  dis- 
tinctive. 

Palpation  may  detect  fluctuation  in  rare  instances.  The 
apex  beat  is  usually  displaced  upward  and  outward,  and 
the  cardiac  shock  is  often  effaced.  It  is  distinctive  to  have 
the  apex  beat  well  within   the   limits   of  cardiac   dulness. 


Fig.  5. — Pericarditis  with  effusion,  show- 
ing the  area  of  dulness.  the  position  of  the 
heart  within  the  pericardial  sac,  and  the  loca- 
tion of  the  apex  beat  (marked  X)  Small 
crosses  mark  the  position  of  the  pericardial 
rales 


174        .V.LVr.'lL    OF   THE   PRACTICE    OF  MEDICLXE 

The  strength  and  location  of  the  apex  beat  are  largely 
influenced  by  the  position  of  the  patient. 

Percussion  shows  an  increased  area  of  cardiac  dulness 
of  a  pyramidal  shape,  the  apex  being  up,  the  broad  base 
of  the  dull  area  producing  a  flat  note  in  the  fifth  and 
even  in  the  sixth  right  interspace.  The  dulness  has  an 
abrupt  outline  and  extends  beyond  and  below  the  apex 
beat.  The  dulness  extends  above  the  normal  limits,  so 
that  very  marked  dulness  above  the  third  rib  should 
lead  to  the  suspicion  of  effusion.  The  surrounding  bor- 
der of  the  lung  frequently  yields  a  tympanitic  percussion 
note  from  its  relaxation.  An  abundant  effusion  extend- 
ing to  the  left  may.  be  mistaken  for  pleurisy.  With  the 
patient  in  a  sitting  position,  dulness,  increased  vocal  frem- 
itus, and  bronchial  voice  and  breathing  may  be  detected 
over  a  small  area  under  the  angle  of  the  left  scapula. 
These  signs  disappear  when  the  patient  leans  forward  or 
assumes  the  knee-chest  position  ;  they  are  due  to  the  pres- 
sure of  an  abundant  effusion  upon  the  lower  lobe  of  the  left 
lung,  and  they  afford  valuable  aid  to  diagnosis,  especially 
in  children  and  young  adults. 

On  auscultation  the  friction  rale  may  be  heard  at  the  base 
of  the  heart ;  the  sound  is  inconstant,  coming  and  going. 
It  returns  with  the  absorption  of  the  fluid.  The  heart  sounds 
are  feeble  and  may  become  inaudible. 

Clmical  Types. —  i.  Latent  Cases. — In  these  cases  the 
symptoms  are  obscured  and  a  diagnosis  is  not  made  during 
the  life  of  the  patient.  Such  cases  commonh-  occur  with 
advanced  Bright's  disease. 

2.  Mild  Cases. — In  these  cases  there  is  no  appreciable 
amount  of  effusion  and  the  m\-ocardium  is  not  involved. 
These  cases  give  symptoms  of  inflammation  and  of  slight 
derangement  of  the  heart's  action. 

3.  Severe  cases  are  those  with  abundant  effusion  asso- 
ciated with  myocarditis.  Symptoms  of  inflammation  and 
cardiac  failure  occur,  and  pressure-symptoms  appear  ac- 
cording to  the  amount  of  the  effusion. 

4.  If  complicated  by  previous  or  coexisting  endocarditis, 
compensation  may  be  upset  and  symptoms  of  cardiac  fail- 


PEIUCARDFTIS. 


175 


ure  with  venous  congestions  may  occur.  The  presence  of 
these  latter  symptoms  indicates  more  than  mere  pericar- 
ditis :  they  point  always  to  a  complicating  myocarditis  or 
endocarditis. 

5.  In  some  cases  delirium,  mania,  or  hallucinations  may 
give  to  the  disease  a  cerebral  character. 

The  diagnosis  in  many  cases  is  exceedingly  obscure. 
The  points  of  diagnosis  from  dilated  heart  are  concisely 
given  by  Sansom  : 


Pericarditis. 


Dilatation. 


Outline  of  dul- 
ness. 

Rate  of  devel- 
opment of 
dulness. 

Impulse  and 
apex  beat. 


Relation  of 
dulness  to 
left  apex 
beat. 

Pain  over 
preco  rdium 
and  tender- 
ness in  epi- 
gastrium. 

Pulsation  in 
veins  of  the 
neck. 

Etiology. 


Fever. 


Dulness  pear-shaped,  and  the 
enlargement  chiefly  upward. 

Often  rapid  and  then  charac- 
teristic. 

The  impulse  when  present  is 
in  the  third  or  fourth  left 
interspace ;  apex  beat  tilted 
upward  and  outward  or 
effaced. 

Dulness  may  extend  to  the 
left  of  the  left  apex  beat. 


Often  present. 


May  be  present  if  endocardi- 
tis complicates. 

Usually  acute,  in  course  of 
acute  rheumatism,  cirrhotic 
Bright's  disease,  etc. 

Often  present. 


Dulness  not  pear-shaped,  and 
enlargement  chiefly  down- 
ward. 

Usually  very  slow,  though  a 
rapid  dilatation  of  the  heart 
sometimes  occurs. 

Impulse  can  usually  be  felt  to 
the  left  of  the  lower  end  of 
the  sternum  or  in  the  epi- 
gastrium. 

Dulness  does  not  extend  to 
the  left  of  the  left  apex 
beat. 

Usually  absent. 


Often  present  when  right 
heart  is  dilated. 

Usually  chronic ;  often  asso- 
ciated with  chronic  vahoi- 
lar  lesions,  fatty  and  fibroid 
degeneration,  anaemia,  etc. 

Absent  unless  from  some 
complication. 


The  characteristics  of  the  friction  rale  already  described 
should  prevent  its  being  mistaken  for  endocardial  murmur. 

Pleuritic  frictions  may  be  so  modified  by  the  movements 
of  the  neighboring  heart  as  to  resemble  closely  the  pericar- 
dial rub.  The  pericardial  friction  is  less  liable  to  variation 
and  is  best  heard  when  the  heart  is  least  covered  by  lung 
— that  is,  during  expiration — while  with  the  pleuro- 
pericardial  sound  the  reverse  is  true. 


176        J/.t.VrJL    OF  THE    PRACTICE    OE  MEDIC  EXE. 

.  Pericardial  effusion  will  not  be  mistaken  for  pleurisy  with 
effusion  if  careful  examination  be  made. 

The  prognosis generall}-  is  good.  It  depends  (i)  upon  the 
cause  of  the  disease,  being  worse  in  distinctly  septic  cases 
and  in  old  people  with  advanced  nephritis ;  (2)  upon  the 
severity  of  the  lesion ;  and  (3)  upon  the  condition  of  the 
heart  itself — how  it  does  its  work,  and  whether  it  be  the  seat 
of  myocarditis  or  of  previous  or  complicating  endocarditis. 
The  prognosis  of  cases  occurring  with  pneumonia  is  better 
than  that  of  any  other  form.  The  ultimate  effect  of  peri- 
cardial adhesions  remaining,  embarrassing  the  work  of  the 
heart  and  leading  to  cardiac  dilatation  or  sudden  death, 
must  enter  into  the  prognosis  of  every  case. 

Treatment. — The  patient  should  be  put  to  bed  and  kept 
absolutely  quiet  mentally  and  bodily.  The  bowels  should 
be  opened  by  calomel  and  Epsom  salt.  To  control  the 
inflammation  continuous  application  of  cold  by  ice-bags  or 
b\'  Leiter's  tubes  is  often  of  the  greatest  service.  Counter- 
irritation  by  cups,  poultices,  blisters,  or  tincture  of  iodine 
may  be  resorted  to,  and  local  blood-letting  by  leeches  ap- 
plied to  the  precordium  may  be  employed  in  robust  sthenic 
cases.  Small  doses  of  opium  are  serviceable  in  steadying 
the  heart  and  controlling  the  symptoms.  Aconite  should 
be  given  in  case  of  tumultuous  heart-action,  to  reduce  the 
work  of  the  heart  to  a  minimum. 

Should  symptoms  of  a  failing  heart  appear,  stimulants 
are  indicated,  whiskey  and  digitalis  being  the  most  efficient. 

To  promote  absorption  of  the  effusion,  blisters  over  the  pre- 
cordium are  recommended.  The  bowels  should  be  opened 
freely,  if  the  patient  is  not  debilitated  by  over-catharsis,  and 
diuretics  should  be  given,  an  efficient  combination  being  the 
infusion  of  digitalis  with  iodide  and  acetate  of  potassium. 

When  the  effusion  is  giving  rise  to  pressure-symptoms 
and  cannot  be  absorbed  by  the  foregoing  measures,  aspira- 
tion may  be  performed.  Puncture  is  best  made  in  the  fifth 
left  interspace  about  two  inches  from  the  sternum — roughly, 
therefore,  in  the  position  of  the  normal  apex  beat. 


PURULENT  rERICARDiriS.  lyy 

PURULENT    PERICARDITIS. 

Btiolog-y. — This  form  of  pericarditis,  which  results  from 
infection  by  the  bacteria  of  suppuration,  comphcates  the 
septic  and  pya^mic  diseases  already  alluded  to  as  causative 
of  pericarditis.  The  disease  is  frequently  seen  with  influenza. 
Infection  of  a  serous  effusion  may  occur  from  the  use  of  an 
infected  aspirating  needle.  It  may  occur  with  pneumonia 
due  to  diplococcus  infection.  The  tubercular  form  of  puru- 
lent pericarditis  will  be  described  in  a  separate  article. 

Pathology. — The  pericardium  is  thickened  and  is  infil- 
trated with  fibrin,  serum,  and  pus-cells  ;  its  superficial  layers, 
which  are  converted  to  granulation-tissue,  may  present  dis- 
tinct ulcerations.  The  pericardium  is  usually  covered  with 
a  thick  layer  of  fibrin  and  pus.  The  effusion  is  distinctly 
purulent  and  is  usually  abundant,  at  times  exceeding  three 
liters.  The  myocardium  is  always  more  or  less  involved ; 
it  may  be  the  seat  of  an  acute  myocarditis  or  of  a  fatty 
degeneration. 

The  suppurative  process  may  extend  in  any  direction,  so 
that  the  effusion  may  rupture  into  a  bronchus  or  into  the 
trachea,  or  may  appear  externally  through  the  thoracic 
wall.  In  rare  cases  the  pus  may  be  absorbed  partially, 
cheesy  deposits  alone  remaining  on  the  surface  of  the  peri- 
cardium, which  becomes  thickened  and  may  be  infiltrated 
with  lime  salts.  Should  the  pus  be  withdrawn  by  opera- 
tion, the  pericardium  may  become  thickened  and  adherent, 
or  it  may  remain  as  a  chronic  suppurating  surface  discharg- 
ing its  contents  through  a  thoracic  fistula. 

In  long-continued  cases  amyloid  changes  occur  in  the 
arteries,  spleen,  liver,  and  kidneys,  and  chronic  diffuse 
nephritis  is  likely  to  develop. 

The  symptoms  are  generally  those  of  serous  pericarditis. 
The  inflammatory  symptoms  are  the  same,  but  they  are 
likely  to  be  obscured  by  those  of  the  original  septic  disease, 
so  that  the  pericarditis  may  escape  unnoticed.  The  symp- 
toms of  mechanical  pressure  are  identical  with  those  of  the 
serous  form.  Myocarditis,  however,  being  more  extensive, 
gives  prominent  symptoms — heart  failure,  rapid  and  feeble 
pulse,  cerebral  anaemia,  dyspnoea,  and  even  venous  conges- 

12 


1/8        M.!\i'A/.    OF  Tl/fi   PRACTICE    OF  MEDICINE. 

tions.  Septic  s)'niptoms  make  their  appearance  and  indi- 
cate, the  presence  of  pus — erratic  chills  followed  by  sud- 
den rises  in  temperature,  cold  sweating,  rapid  and  feeble 
pulse,  diarrluea,  and  a  low  form  of  delirium. 

The  physical  signs  are  those  of  pericardial  effusion. 
Should  pointing  occur,  the  skin  becomes  red  and  shining 
and  fluctuation  may  be  detected.  In  case  of  doubt  as  to 
the  nature  of  the  effusion,  hypodermic  aspiration  under 
antiseptic  precautions  should  be  employed. 

The  prognosis  is  bad.  The  primary  septic  disease  may  of 
itself  be  fatal.  The  myocarditis  is  apt  to  lead  to  dangerous 
heart  failure,  and  even  if  the  effusion  be  removed  by  opera- 
tion, the  pericardium  never  returns  to  a  normal  condition, 
and  the  danger  of  adhesive  pericarditis  should  be  con- 
sidered. The  prognosis  of  cases  complicating  pneumonia 
is  less  grave  than  in  the  other  forms. 

Treatment  is  entirely  surgical.  The  pericardium  should 
be  opened  freely  and  drained.  The  opening  should  usually 
be  made  in  the  fifth  interspace,  one  and  a  half  inches  from 
the  edge  of  the  sternum  to  the  left. 

CHRONIC    ADHESIVE    PERICARDITIS. 

Etiology  and  Pathology. — Thickening  of  the  pericardium 
and  the  formation  of  connective-tissue  adhesions  between 
its  opposed  surfaces  follow  diy  pericarditis  or  the  absorp- 
tion of  the  serous  effusion.  This  condition  may  also  follow 
absorption  of  a  sero-purulent  exudate,  the  pericardium  being 
thickened  by  connective  tissue  covered  with  a  cheesy 
deposit  and  often  infiltrated  with  salts  of  lime.  If  the 
adhesions  are  such  as  not  to  impede  the  action  of  the  heart, 
there  may  be  little  or  no  change  in  its  structure.  If  the 
adhesions  are  firm  and  short,  the  impediment  afforded  to 
the  free  action  of  the  heart  leads  to  hypertrophy,  frequently 
of  enormous  dimensions.  Thus  compensation  is  estab- 
lished. Fatty  degeneration  and  dilatation  finally  result  in 
heart  failure.  Pleuro-pericardial  adhesions  are  usually 
present. 

Symptoms. — As  long  as  the  heart's  power  is  good, 
symptoms  are  indefinite  and  may  be  absent.     When  myo- 


TUBERCULAR   PRRTCARDITIS.  1 79 

cardial  degeneration  and  dilatation  ensue,  symptoms  of 
failure  of  cardiac  power  result,  as  shown  by  arterial  anaemia 
and  venous  congestions.  The  pulse  becomes  weak  and 
irregular,  and  the  pulsus  paradoxus  may  be  noted.  There 
may  be  attacks  of  angina,  and  sudden  death  may  occur. 
There  are  frequently  observed  recurring  attacks  of  acute 
dry  pericarditis. 

Physical  Signs. — The  heart  is  usually  hypertrophied. 
It  may  be  dilated,  and  there  may  be  the  systolic  apical 
murmur  of  relative  incompetence  of  the  mitral  valve.  A 
significant  sign  is  the  retraction  of  the  apex  during  systole. 
This  sign,  however,  is  not  absolutely  diagnostic,  and  it  may 
be  absent.  After  the  systolic  retraction  the  chest-wall  may 
suddenly  rebound  during  diastole,  often  with  a  sharp 
shock.  The  rapid  rebounding  of  the  chest-wall  may  sud- 
denly empty  the  jugular  veins,  giving  rise  to  the  "  diastolic 
collapse,"  or  Friedreich's  sign. 

The  heart  sounds  may  be  normal,  or  muffled  if  the  peri- 
cardial layers  be  greatly  thickened.  There  may  be  distinct 
and  persistent  friction  sounds,  often  of  a  grating,  creaking, 
or  "  new-leather  "   character. 

The  prognosis  is  not  good.  Compensation  is  almost  cer- 
tain to  be  upset  by  myocardial  degeneration  and  dilatation. 
Sudden  death  often  occurs. 

Treatment  consists  in  steady  counter-irritation  applied  to 
the  precordium,  and  the  treatment  of  cardiac  weakness 
when  it  occurs.  Avoidance  of  severe  or  sudden  exertion  is 
to  be  enforced  strictly. 

TUBERCULAR   PERICARDITIS. 

Tuberculosis  of  the  pericardium  may  be  part  of  a  general 
infection  or  it  may  be  a  local  disease.  It  is  of  rare  occur- 
rence, and  usually  results  from,  extension  from  tubercular 
disease  of  the  bronchial  or  mediastinal  glands,  the  lungs,  or 
the  pleurae,  although  in  many  cases  the  primary  lesion  may 
be  so  slight  as  to  pass  unnoticed. 

Pathology. — Four  forms  of  the  lesion  are  seen  :  (i)  The 
pericardium  is  thickened  by  imbedded  tubercules ;  its  sur- 
face is  congested  and   covered  with  fibrin.     (2)  The  peri- 


I  So        .V.-J.Vr.l/.    OF   THE   PRACTICE    OF  MEDICINE. 

cardiuni  resembles  the  first  form,  but  there  is  an  exudate  of 
serum  as  well.  (3)  The  pericardium  is  bright  red  and 
studded  with  white  points,  which  are  the  tubercules.  There 
is  a  hemorrhagic  effusion.  (4)  The  pericardium  i.s  thickened 
and  infiltrated  with  connective-tissue  cells  and  masses  of 
tubercle-tissue  ;  its  surface  is  coated  with  fibrin,  pus.  and 
broken-down  tubcrcle-tissuc.  There  is  a  purulent  effusion 
often  containing  shreds  of  cheesy  tissue  in  which  the  bacilli 
are  to  be  found. 

The  symptoms  of  tubercular  pericarditis  resemble  those 
of  the  non-tubercular  forms  in  essential  features  and  physi- 
cal signs.  They  differ  in  the  following  particulars:  (i)  The 
disease  is  insidious,  the  first  symptoms  usually  being  weak- 
ness, loss  of  flesh,  and  ansemia.  (2)  The  symptoms  are  per- 
sistent, without  tendency  to  improvement.  The  effusion 
recurs  in  spite  of  drug-treatment  or  aspiration.  (3)  The 
course  of  the  disease  is  steadily  downward.  Recovery  is 
possible,  though  rare,  and  is  not  to  be  expected  except  in 
slight  lesions. 

Diagnosis  is  aided  by  the  absence  of  the  ordinary  causes 
of  pericarditis  and  by  the  presence  of  tubercular  lesions, 
especially  within  the  thorax.  Double  pleurisy  with  effusion 
or  with  pericarditis  is  almost  always  tubercular.  Hemor- 
rhagic effusion  may  occur  in  pericarditis  of  the  aged  or  the 
scorbutic,  but  is  much  more  significant  of  tuberculosis  or  of 
cancer.  The  finding  of  tubercle  bacilli  in  the  pericardial 
effusion  will  of  course  settle  the  diagnosis  past  all  dispute. 

Treatment  is  that  of  the  pericarditis  after  established  prin- 
ples,  and  of  the  general  condition  by  the  supporting  treat- 
ment that  is  employed  in  all  tubercular  cases. 

CANCEROUS   PERICARDITIS. 

Cancer  or  sarcoma  of  the  pericardium  is  rare  and  is 
almost  never  primary.  Besides  the  malignant  new  growths 
the  pericardium  presents  the  lesions  of  simple  inflammation 
with  serous,  or  more  frequently  with  hemorrhagic,  exudate. 

The  symptoms  are  those  of  a  slowly-developing  pericar- 
ditis with  effusion.  Pain  is  often  lancinating  and  excessive. 
Aid  is  afforded  in  diagnosis  by  the  hemorrhagic  character 


HYDROPERTCAKDIUM — rNEUMOPERICARJDIUM.      I  <S  I 

of  the  effusion  (as  in  tubercular  peritonitis),  the  presence  of 
the  primary  malignant  growth,  and  the  symptoms  of  can- 
cerous or  sarcomatous  cachexia. 

The  prognosis  is  invariably  bad. 

Treatment  is  merely  palliative.  Injections  of  toxic  prod- 
ucts of  erysipelas  germs  may  be  employed  in  sarcomatous 
cases, 

HYDROPERICARDIUM. 

Large  serous  effusions  without  inflammatory  signs, 
constituting  "  dropsy  of  the  pericardium,"  occur  in  con- 
nection with  general  dropsy,  usually  due  to  kidney  or  heart 
disease. 

Symptoms. — Associated  with  dropsical  effusions  in  the 
pleural  cavities,  this  condition  embarrasses  the  action  of  the 
heart  and  the  lungs.  The  disease  may  occur  after  scarlet 
fever  without  general  dropsy.  There  are  no  inflammatory 
symptoms. 

Physical  Signs. — The  physical  signs  are  those  of  effusion, 
but  there  is  no  friction  rale. 

H^MOPERICARDIUM. 

Blood  in  the  pericardium  results  from  rupture  of  an 
aneurysm  of  the  first  part  of  the  aorta,  of  the  coronary 
arteries,  or  of  the  heart  itself,  from  rupture  of  the  heart-wall 
in  myocarditis,  or  from  penetrating  wounds  or  severe  crush- 
ing of  the  thorax. 

The  symptoms  are  those  of  heart  failure  and  of  hemor- 
rhage in  general.  When  the  hemorrhage  occurs  slowly, 
the  symptoms  of  heart  failure  may  be  obscured  by  nausea 
and  vomiting.  Pericarditis  with  bloody  effusion  cannot 
properly  be  called  haemopericardium. 

The  prognosis  is  bad.  Recovery,  however,  may  occur  in 
case  but  little  blood  has  been  lost. 

PNEUMOPERICARDIUM. 

Air  in  the  pericardial  sac  may  occur  from  penetrating 
wounds  of  the  chest  or  from  perforation  of  the  lungs, 
oesophagus,  or  stomach.     Gas  may  result  from  the  decom- 


1 82        .WA.Vr.lL    OF   THE   PKACT/CE    OF  MEDICINE. 

position  of  a  purulent  exudate.  Acute  pericarditis  is  always 
excited,  in  most  cases  with  a  purulent  exudation. 

The  symptoms  are  those  of  cardiac  foilurc — fever  and 
pericardial  effusion.     Death   usually  follows  rapidly. 

Physical  Signs. — It  is  characteristic  of  pneumopericar- 
dium to  ha\'e  a  movable  area  of  dulness  over  the  fluid, 
with  an  overl}'ing  area  of  t\-mpany  over  the  gas.  The 
heart  sounds  may  be  distant  and  feeble  but  of  a  metallic 
gravity.  There  are  splashing,  churning  sounds  of  a  metal- 
lic quality  with  frictions. 

The  diagnosis  is  to  be  made  from  dilated  stomach, 
sacculated  pyopneumothorax,  large  superficial  pulmonary 
cavity,  and  in  rare  cases  from  hernia  of  intestine  through  a 
congenital  opening  in  the  diaphragm. 

The  prognosis  is  almost  hopeless  except  in  recent  trau- 
matic cases. 

Treatment  consists  in  free  incision  and  drainage. 


2.  DISEASES  OF  THE   HEART. 

HYPERTROPHY  AND  DILATATION. 

The  heart  is  an  organ  with  a  definite  function — to  main- 
tain the  circulation  of  the  blood — and  its  diseases  are 
important  only  to  the  extent  to  which  they  modify  this 
function.  Tlie  effect  of  all  cardiac  lesions  is  one :  tlie  heart 
is  prevented  from  doing  its  xvork.  The  variety  of  the  lesion 
is  less  important  than  its  results  on  the  power  of  the  heart. 

There  are  three  things  to  be  considered  in  the  work  of  a 
normal  heart:  (i)  The  heart  is  a  hollow  muscle  contracting 
on  its  contents ;  (2)  the  heart  drives  the  blood  against 
resistance;  (3)  the  onward  flow  of  blood  is  facilitated  by 
the  perfect  condition  and  action  of  the  valves.  Any  one 
of  these  three  conditions  may  become  deranged,  and  so 
cause  interference  with  the  work  of  the  heart. 

Causes  Preventing  the  Heart  from  doing  its  "Work. — 
L  Weakness  of  the  He.'^rt-muscle. — This  weakness  may 
be  either  comparative  or  actual. 

I.     Comparative     Weakness. — Here    the    heart,    though 


HYPERTROPHY  AND  DIJ.ATATJON.  1 83 

normal  in  strength,  is  not  strong  enougli  to  do  an  extra 
amount  of  work  that  may  be  required  of  it.  This  con- 
dition is  seen  in  severe  and  sudden  over-exertions,  as  in 
rowing-races,  especially  without  previous  training,  or  in 
exertion,  even  to  a  moderate  extent,  in  high  altitudes,  or 
when  the  proper  expansion  of  the  chest  is  prevented,  as  by 
the  heavy  cross-straps  of  soldiers  on  the  march,  the  action 
of  the  heart  becoming  secondarily  embarrassed  and  in- 
sufficient to  meet  the  demands  made  upon  the  organ. 

2.  Actual  weakness  is  the  more  important  form,  not  only 
because  it  is  continuous  in  its  action,  but  also  because  the 
heart  is  rendered  unfit  to  meet  the  demands  of  ordinary  life. 
The  heart-muscle  may  become  weakened  in  the  following 
ways : 

{a)  By  degeneration,  either  acute,  as  in  fevers  and  infec- 
tious diseases,  or  chronic,  as  in  fatty  heart. 

{]})  By  inflaniniation,  either  acute,  as  in  acute  myocarditis, 
which  so  commonly  complicates  pericarditis,  or  chronic,  as 
in  chronic  interstitial  myocarditis. 

(c)  By  poor  nutrition,  (i)  In  some  cases  the  nutrition  of 
the  whole  body  suffers  as  well  as  the  heart,  as  during  con- 
valescence from  a  prolonged  fever  or  in  the  case  of  profound 
ansemia,  the  heart  as  well  as  the  other  organs  being  poorly 
supplied  with  blood,  frequently  giving  rise  to  dilatation  and 
cardiac  symptoms.  (2)  In  other  cases  the  heart  alone  suffers. 
This  condition  arises  when,  by  reason  of  atheroma  of  the 
coronary  arteries,  the  supply  of  blood  to  the  heart-muscle 
itself  is  lessened. 

II.  Increased  Peripheral  Resistance. — It  is  important 
to  remember  that  increased  peripheral  resistance  may  occur 
either  in  the  systemic  vessels,  interfering  in  consequence 
with  the  action  of  the  left  side  of  the  heart,  or  in  the  pul- 
monary vessels,  interfering  with  the  work  of  the  right  heart. 
Each  system,  then,  must  be  considered  separately. 

I.  Increased  peripheral  resistance  in  the  systemic  circula- 
tion, affecting  the  work  of  the  left  heart. 

(a)  By  atheroma  or  aneurysm  of  the  aorta  or  great  vessels. 

(<^)  By  endarteritis,  because  of  the  narrowed  lumen  and  the 
non-yielding  walls  of  the  small  arteries. 


184        MAXUAL    OF   THE    PRACTICE    OF  MEDICINE. 

■  [c)  By  spasm  of  tlic  suiall  arteries.  The  spasm  may  occur 
as  (i)"the  result  of  an  endarteritis,  or  (2)  from  Bright's 
disease,  (3)  uric-acid  diathesis,  (4)  gout,  (5)  diabetes,  or  (6) 
over-eating  and  excessive  drinking. 

2.  Increased  peri  plural  resistance  to  the  puluuviary  circu- 
lation^ affecting  the  i^-'ork  of  the  right  heart. 

{a)  By  failure  of  the  left  heart,  either  from  its  muscular 
weakness,  from  dilatation,  or  from  wah  ular  disease,  espe- 
cially lesions  of  the  mitral  valve. 

{b)  By  obstructio7i  of  the  pubnonaiy  vessels  by  spasm, 
endarteritis,  or  obliteration.  This  condition  occurs  in  em- 
physema, in  interstitial  pneumonia,  and  to  sonic  extent  in 
pulmonary  phthisis. 

III.  Error  in  the  Valves. —  i.  By  stenosis  of  any  valve, 
the  vah^e-orifice  becoming  narrowed,  there  is  difficulty  in 
the  onward  passage  of  the  blood. 

2.  By  insufficiency  of  any  valve,  so  that  blood  can  regur- 
gitate backward  instead  of  being  prevented  from  so  doing 
by  perfect  closure  of  the  valve. 

Valvular  insufficiency  may  result  in  one  of  four  ways : 

{a)  By  inflammation,  causing  thickening  and  contraction 
of  the  valve. 

(b)  By  rupture  from  violence  or  from  ulceration. 

{c)  By  stretching  of  the  orifice  to  which  the  valve-segments 
are  attached.  This  applies  especially  to  the  mitral  valve. 
The  mitral-valve  segments  can  close  the  left  auriculo-ven- 
tricular  orifice,  provided  it  be  of  normal  size;  but  should 
the  left  ventricle  become  dilated,  the  auriculo-ventricular 
orifice  becomes  stretched  to  too  great  a  size  to  be  covered 
by  the  valve-segments  during  their  closure,  hence  regurgi- 
tation of  blood  is  permitted  at  the  time  of  the  ventricular 
systole.  This  condition  is  often  spoken  of  as  "  relative 
incompetence." 

Regurgitation  into  the  left  ventricle  may  occur  at  the 
time  of  the  ventricular  diastole,  past  the  aortic  valve  if  the 
aortic  ring  be  stretched  by  an  aneurysm  of  the  aorta  near 
the  valves,  even  if  the  latter  be  normal. 

(^)  By  poor  ventricular  contraction.  The  relation  of  mus- 
cular fibres  to  the  mitral  ring  is  such  that  when  the  fibres 


IIYPEKTROPUY  ANJ)   Dfl.ATAl'/ON.  I  85 

contract  the  auriculo-ventricular  orifice  is  reduced  to  one- 
half  its  size  and  can  then  be  covered  by  the  normal  valve- 
segments.  If  the  contraction  be  poor,  the  orifice  is  not  so 
much  diminished  in  size,  and  cannot  be  closed  entirely  by 
the  valve-segments.  In  this  way  regurgitation  of  blood 
past  the  mitral  valve  is  permitted  at  the  time  of  ventricular 
contraction.  To  this  condition  the  name  of  "  relative  in- 
competence "  is  also  applied. 

Methods  of  Compensation. — When  an  extra  amount  of 
work  is  required  of  the  heart  in  any  of  the  above-mentioned 
ways,  the  great  and  important  question  is  whether  the  heart 
can  rise  to  the  emergency  and  meet  the  demand  for  the 
extra  amount  of  work.  When  the  increased  power  of  the 
heart  becomes  equal  to  the  increased  demand,  then  the  cir- 
culation is  again  in  an  equilibrium  and  "  compensation  "  is 
established.  Upon  the  question  of  compensation  the  whole 
prognosis  and  treatment  of  cardiac  diseases  depend.  Com- 
pensation occurs  in  two  ways  : 

1.  By  increase  of  the  force  and  frequency  of  the  hearfs  action. 
This  is  the  simplest  form  of  compensation,  and  is  especially 
adapted  to  meet  sudden  demands.  The  rapid  and  forcible 
heart's  action  after  a  short  run  is  the  best  example  that  can 
be  cited.  Compensation  by  increase  of  the  heart's  action  is 
often  associated  with  hypertrophy,  and  it  is  most  important 
that  this  fact  be  remembered.  For  example,  in  aortic 
regurgitation  hypertrophy  of  the  left  ventricle  is  hardly 
sufficient  by  itself  to  compensate  for  the  diastolic  regurgi- 
tation of  blood.  There  must  also  be  an  increased  fre- 
quency of  ventricular  contraction  to  keep  the  ventricle 
emptied  of  the  blood  which,  during  diastole,  pours  into  it 
not  only  from  the  auricle,  but  backward  as  well  from  the 
aorta,  past  the  inefficient  aortic  valve.  It  is  poor  practice  to 
try  to  reduce  the  pulse-rate  of  such  a  case  to  the  normal 
limit  of  72  to  the  minute.  If  we  do,  we  run  the  risk  of  giv- 
ing the  ventricle  time  enough  between  contractions  to  be- 
come distended  to  too  great  a  limit,  with  disastrous  results. 

2.  By  hypertrophy. 


1 86        MAXrAL    OF  THE  PRACTICE    OF  MEDICINE, 


Hypertrophy. 
Hypertrophy  is  an  actual  increase  in  the  amount  of 
cardiac  muscle,  giving  tlie  heart  thereby  increased  force 
adequate  to  the  increased  demand  for  force.  The  condition 
is  purel}'  compensator}-  and  ph)^siological,  and  is  analogous 
to  the  enlargement  of  the  biceps  of  a  blacksmith.  Certain 
conditions  must  be  complied  with  before  hypertrophy  can 
occur. 

1.  A  certain  amount  of  time  is  necessary.  Hypertrophy 
is  a  slow  process,  requiring  a  minimum  time  of  two  weeks 
for  its  development.  Preceding  its  completion  there  may 
be  a  primary  compensation  by  increased  force  and  fre- 
quency of  the  heart's  action.  The  process  of  hypertrophy 
is  so  slow  that  patients  may  die  from  disturbed  circulation 
before  compensation  is  established. 

2.  The  lesion  must  not  be  excessive.  It  can  readily  be  seen 
that  in  vtxy  extensive  lesions  no  amount  of  muscular 
hypertrophy  can  restore  the  circulation  to  an  equilibrium. 

3.  TJic  lesion  must  not  be  too  rapidly  piv^ressive.  A  lesion 
slight  at  first  may  be  perfectly  compensated,  but  if  it  pro- 
gresses it  may  become  too  severe  for  hypertrophy  to  keep 
up  with  it. 

4.  There  must  be  a  healthy  condition  of  the  heart-muscle. 
This  is  of  the  utmost  importance.  Weakness  of  the  heart- 
muscle  may  prevent  hypertrophy  entirely  or  may  only  allow 
a  degree  of  hypertrophy  inadequate  to  the  demand,  so  that 
compensation  occurs  but  imperfectly.  Weakness  of  the 
heart-muscle  ma}'  at  any  time  prevent  the  maintenance  of 
hypertrophy,  so  that  compensation  will  fail.  The  treatment 
of  a  hypertrophied  heart  consists  solely  in  the  maintenance 
of  a  proper  amount  of  hypertrophy,  and  this  state  depends 
in  the  greatest  degree  upon  the  condition  of  the  heart-mus- 
cle itself  It  is  important,  then,  to  consider  in  what  ways 
the  heart-muscle  may  be  weakened. 

Local  Causes. —  (i)  DegeneratioJi,  either  fatty,  fibroid,  or 
the  acute  degeneration  of  fevers ;  (2)  infaimnatioji  as 
complicating  acute    endocarditis    or  pericarditis ;    (3)  poor 


I/YPEK  TROPIIY  AND   Dff.A  '/A  TION.  1 8/ 

blood-supply ,  from  atheroma  of  the  coronary  artery  or  from 
severe  general  anjemia. 

General  Causes. — (i)  General  weakness  and  debility; 
(2)  old  age;  (3)  anaemia;  (4)  lack  of  proper  care  of  self; 
indulgence  in  alcohol  and  tobacco,  irregular  hours  and 
habits,    exhausting    work,    improper  food,  etc. 

Symptoms  of  Hypertrophy. — If  there  be  compensatory 
hypertrophy  adequate  to  meet  the  extra  demand  on  the 
heart,  the  circulation  will  be  in  perfect  equilibrium  and  there 
will  be  no  subjective  symptoms.  The  diagnosis  is  made  by 
the  finding  of  some  cause  demanding  the  performance  of 
extra  work.  This  cause  may  be  valvular  error  or  increased 
peripheral  resistance  from  endarteritis  or  from  the  arterial 
spasm  of  Bright's  disease,  or  from  any  of  the  other  men- 
tioned causes,  but  in  all  cases  alike  perfect  compensation 
allows  of  no  circulatory  disturbances. 

Physical  Signs  of  Hypertrophy  of  the  Left  Side  of  the 
Heart, — Inspection  may  show  some  bulging  of  the  pre- 
cordia,  especially  in  children,  in  whom  asymmetry  of  the 
chest  may  become  apparent.  The  area  of  visible  impulse 
is  much  increased,  and  the  apex  beat  is  seen  to  be  displaced 
downward  and  outward. 

Palpation. — There  occurs  over  the  lower  part  of  the  heart 
a  slow,  heaving  impulse  which  is  one  of  the  most  distinctive 
signs  of  simple  hypertrophy.  The  apex  beat  occurs  as  a 
powerful,  deliberate  thrust,  and  is  felt  downward  and  out- 
ward from  its  normal  situation.  It  may  be  felt  in  the  sixth, 
seventh,  or  eighth  intercostal  space  and  outside  the  nipple 
line.  The  position  of  the  apex  beat  is  a  good  guide  to  the 
position  of  the  left  border  as  found  by  auscultatory  percus- 
sion. If  the  apex  beat  be  continuously  strong  and  heaving, 
it  proves  a  healthy  condition  of  the  myocardium  and  is  of 
good  prognostic  value.  The  character  of  the  apex  beat  aids 
in  differentiating  hypertrophy  from  dilatation.  In  some 
patients  with  deep,  well-covered  chests,  and  in  those  whose 
lungs  are  emphysematous,  overlapping  the  heart  to  an  ab- 
normal degree,  the  signs  by  inspection  and  palpation  may 
not  be  apparent. 

Percussion  should  by  preference  be  performed  by  the  aus- 


1 88        M.iXr.if.    OF   THE   PRACTICE    OF  MEDICINE, 

cultatory  method,  as  greater  accuracy  is  thereby  assured. 
There  is  increase  in  the  transverse  area  of  duhiess,  so  that 
the  left  border  Hes  distinct!}-  outside  the  nipple  line.  A 
transverse  diameter  of  over  four  and  a  half  inches  is  never 
seen  in  a  normal  heart.  In  some  cases  the  transverse 
diameter  is  not  increased  by  percussion,  so  that  the 
diagnosis  must  be  made  by  other  signs.  There  is  also 
an  increase  in  the  vertical  direction,  the  upper  limit  of 
cardiac  dulness  being  frequently  in  the  second  intercostal 
space. 

Aiisciilfatioii. — In  h\-pcrtrophy  without  valvular  disease  the 
sounds  of  the  heart  may  be  normal,  or  the  first  sound  at  the 
apex  may  be  prolonged  and  of  a  booming,  muscular  quality. 
Reduplication  is  common  in  the  hypertrophy  consequent 
upon  kidney  disease.  The  second  sound  heard  over  the  aortic 
area  is  loud,  clear,  and  snappy,  being  "  accentuated."  This  ac- 
centuation of  the  second  aortic  sound  is  heard  best  in  hyper- 


FiG.  6. — Sphygmogr.im  showing  high  tension  in  Bright's  hypertrophy. 

trophy  consequent  upon  increased  arterial  resistance.  For 
its  development  there  must  be  not  only  increased  resistance 
in  front,  but  also  increased  force  from  behind,  so  that  at  each 
systole  blood  is  pumped  into  the  aorta  with  force  enough  to 
give  rise  to  tension  high  enough  to  overcome  the  increased 
peripheral  resistance.  The  accentuation  is  due  to  the  forcible 
closure  of  the  aortic  valves  at  the  beginning  of  diastole  by 
reason  of  this  high  arterial  pressure.  The  very  presence  of 
an  accentuation  of  the  second  aortic  sound  is  of  good 
prognostic  significance,  as  it  proves  necessarily  that  the 
heart  is  able  to  do  its  extra  work.  The  disappearance  of 
the  accentuation  and  the  weakening  of  the  second  aortic 
sound  imply  weakening  of  the  heart's  power,  and  are  of 
bad  import. 

In  hypertrophy  dependent  upon  valvular  lesions  the  heart 


jiypERriwrnY  and  DfLATA770N.  189 

sounds  are  necessarily  altered  and  are  replaced  or  associated 
with  murmurs. 

In  hypertrophy  associated  with  dilatation  the  physical 
signs  are  correspondingly  modified. 

The  pulse  of  hypertrophy  not  due  to  valvular  disease  is 
full,  strong,  and  of  high  tension.  Its  characteristics  are 
best  seen  in  cases  of  hypertrophy  consequent  upon  in- 
creased peripheral  resistance,  as  endarteritis  in  Bright's 
disease. 

Physical  Sig-ns  of  Hypertrophy  of  the  Rig-ht  Side  of  the 
Heart. — Inspection  may  reveal  bulging  of  the  lower  part 
of  the  sternum.  Below  the  ensiform  cartilage  there  is  a 
visible  pulsation  due  to  the  enlargement  downward  of  the 
hypertrophied  right  ventricle. 

Palpation. — There  is  a  distinct  heaving  impulse  appre- 
ciable just  below  the  ensiform  cartilage.  This  epigastric 
pulsation  is  seen  and  felt  also  in  displacement  of  the  heart 
downward  from  aneurysm,  from  mediastinal  tumors,  and 
from  emphysema,  so  that  the  diagnosis  of  hypertrophy  of 
the  right  ventricle  should  always  be  corroborated  by  other 
signs.  The  second  sound  heard  over  the  pulmonary  area 
(second  space  to  the  left  of  the  sternum)  is  accentuated  on  ac- 
count of  increased  tension  within  the  pulmonary  artery.  This 
sign  is  of  good  prognostic  value.  The  diagnosis  is  aided 
by  the  finding  of  the  cause  for  the  hypertrophy  either  in  a 
failing  left  ventricle  or  in  some  condition  causing  increased 
resistance  in  the  pulmonary  circulation. 

Dilatation. 

Dilatation  is  reached  whenever  the  ventricle  does  not 
empty  itself  during  the  systole.  There  are  two  principal 
causes  of  dilatation  : 

I.  Increased  blood-pressnre  within  the  cardiac  cavities,  from 
increased  peripheral  resistance,  from  valvular  disease,  or 
from  excessive  muscular  effort.  An  extra  amount  of  work 
is  thrown  on  the  heart,  which  fails  to  respond  by  hyper- 
trophy, either  by  reason  of  a  too  sudden,  too  extensive,  or 
too  rapidly  progressive  lesion,  or  by  reason  of  impaired 
vitality  of  the  cardiac  muscle. 


190        MAXi'AL    OF   THE   PRACr/CE    OF  MEDICIXE. 

2.  Impaired  nutrition  of  tlic  hcart-n'aUs  may  so  weaken 
their  resisting  power  that  dilatation  occurs  even  if  the  heart 
be  not  called  upon  for  extra  work.  The  condition  is  often 
spoken  of  as  "  idiopathic  dilatation."  The  result  in  either 
case  is  the  same  :  the  heart  can  no  longer  do  its  work.  Three 
conditions  necessarily  result :  (i)  The  arteries  are  underfilled 
with  blood — arterial  anaemia.  (2)  The  veins  are  overfilled, 
and  there  are  venous  congestions  of  the  various  viscera  that 
may  be  acute  or  ma\-  become  chronic.  (3)  The  heart  can- 
not empt}'  itself  completely  at  each  systole,  either  from  too 
much  work  required  or  from  deficient  contraction-force,  so 
that  there  is  always  a  certain  amount  of  residual  blood 
which  increases  the  size  of  the  cardiac  cavities  and  dilates 
them,  especially  if  the  cardiac  muscle  be  weak  and  de- 
generate. 

Hypertrophy  is  a  compensatory  process ;  dilatation  is 
destructive.  Hypertrophy  is  an  evidence  of  vigor ;  dilata- 
tion is  an  evidence  of  weakness.  In  hypertrophy  the  work 
of  the  heart  is  well  done ;  in  dilatation  the  work  is  imper- 
fectly performed. 

Dilatation  may  occur  by  itself  or  may  be  associated  with 
hypertrophy.  In  some  cases  hypertrophy  may  precede, 
compensating  for  some  pre-existing  lesion  ;  then  compensa- 
tion fails  and  dilatation  gradually  ensues.  In  other  cases, 
from  a  sudden  lesion  the  heart  is  at  first  dilated,  compen- 
satory hypertrophy  occurring  after  a  time. 

Symptoms. — If  the  left  ventricle  dilates,  its  walls 
become  weakened  and  thinned  and  the  mitral  ring  becomes 
stretched.  From  both  of  these  reasons,  as  previously 
explained,  there  is  apt  to  be  developed  "  relative  incompe- 
tence of  the  mitral  valve,"  the  blood  being  regurgitated  at 
the  time  of  the  ventricular  systole  into  the  auricle,  and  so 
exerting  a  back  pressure  and  congestion  in  the  pulmonary 
vessels.  If  the  right  ventricle  be  strong  and  of  good 
nutrition,  it  will  act  forcibly  and  will  hypertrophy,  forcing 
the  blood  well  into  the  pulmonary  blood-vessels  against 
this  backward  pressure,  standing  thus  as  a  barrier  between 
the  dilated  left  ventricle  and  the  systemic  venous  system. 
If,    on    the    contrar\',    the     risjht    ventricle    be    not    strong 


IIYPERrROPIIY  AND  DH^ATAT/ON.  I9I 

enough  to  overcome  the  backward  pulmonary  pressure  and 
to  sustain  the  circulation  of  blood  in  the  lungs,  the  ven- 
tricle wili  dilate,  its  contraction-force  will  be  weakened,  there 
will  be  back  pressure  of  blood  in  the  veins  of  the  body, 
and  general  venous   congestion  of  the  viscera  will   ensue. 

The  consideration,  therefore,  of  the  symptoms  of  dilata- 
tion is  largely  that  of  venous  congestions. 

Acute  Venous  Congestions. — Brain. — The  pia  mater  is 
congested  and  cedematous.  There  is  an  increase  in  the 
cerebro-spinal  fluid.  Clinically  there  are  developed  delirium 
with  delusions,  insomnia,  stupor,  and  headaches. 

Lungs. — Congestion  and  oedema  exist,  especially  marked 
posteriorly  at  both  bases.  There  may  be  areas  of  hypo- 
static pneumonia.  Clinically  there  is  developed  dyspnoea, 
at  first  only  on  exertion,  later  becoming  steady  and  of  the 
variety  known  as  "  orthopnoea."  There  is  a  cough  with 
expectoration  which  may  contain  blood.  The  expectora- 
tion may  be  serous  and  profuse.  On  physical  examination 
are  found  moist  bronchial  rales  and  crepitations,  either 
general  or  at  the  bases  alone,  and  there  may  be  the  physi- 
cal signs  of  consolidation  in  case  of  hypostatic  pneumonia. 

Plcnra. — There  is  hydrothorax.  This  gives  rise  to 
symptoms  due  to  the  mechanical  presence  of  the  fluid — 
dyspnoea,  cough,  and  the  displacement  of  neighboring 
viscera.  There  are  the  physical  signs  of  fluid  in  both 
pleural    cavities. 

Stomach. — There  is  congestion  of  the  gastric  mucosa, 
giving  rise  to  vomiting,  to  occasional  small  hemorrhages, 
and  to  symptoms  of  gastric  indigestion. 

Intestines. — There  is  either  diarrhoea  or  constipation  and 
a  decided  loss   of  general  nutrition. 

Liver. — There  are  congestion,  an  enlargement  which  is 
slight  and  symmetrical,  symptoms  of  disturbances  in  the 
functions  of  the  liver,  and  frequently  slight  jaundice. 

Spleen. — There  is  moderate  enlargement. 

Peritoneum. — There  is  a  serous  peritoneal  effusion  known 
as  "ascites,"  with  enlargement  of  the  abdomen;  mechanical 
symptoms  of  the  effusion  and  the  physical  signs  of  its 
presence  also  exist. 


192        .h'AXi'AL    OF  THE   PRACTICE    OF  MEDICINE. 

Kidneys. — The  kidneys  are  enlarged  and  congested.  The 
urine  is  diminished;  albumin  and  casts  are  present  in 
moderate  amounts.  A  practical  rule  is  that  whenever  the 
urine  is  turbid  and  deposits  urates  day  after  day  irrespec- 
tive of  diet,  mode  of  life,  or  exercise,  a  failing  heart  should 
be  looked  for. 

Skin. — Cyanosis  appears ;  there  is  also  oedema,  at  first 
appearing  in  the  feet  and  ankles  after  standing,  but  later 
becoming   general. 

Chronic  Venous  Congestions. — Brain. — The  pia  mater 
is  congested  and  cedematous,  and  the  fluid  in  the  ventricles 
is  increased — the  so-called  "  wet  brain."  There  is  apt  to  be 
considerable  atrophy  of  the  cerebral  cortex.  Clinically 
there  are  headache,  attacks  of  dizziness,  black  specks  before 
the  eyes,  buzzing  noises  in  the  ears,  insomnia  or  unnatural 
stupor,  and  delirium  with  delusions. 

Lungs. — There  is  a  chronic  bronchitis  with  cough  and 
expectoration.  There  may  be  repeated  small  hemorrhages. 
Dyspnoea  is  present  at  first  on  exertion,  but  later  becomes 
steady  and  of  the  orthopnoeic  variety'.  In  chronic  cases 
there  is  developed  the  chronic  congestion  of  the  lung  known 
as  the  "pneumonia  of  heart  disease,"  or  "pigment"  or  "brown 
induration."  The  lung  is  dry  and  leathery  and  is  mottled 
brown  and  salmon  pink  in  color.  Microscopic  examination 
shows  dilatation  and  lengthening  of  the  capillaries  in  the 
alveolar  wall,  so  that  by  their  loopings  they  encroach  upon 
the  air-spaces.  The  alveolar  wall  is  thickened  by  the  growth 
of  its  capillaries  and  by  that  of  muscular  fibres  and  new 
connective  tissue.  In  the  walls  of  the  alveoli  and  in  their 
endothelial  cells  there  is  a  deposit  of  pigment  due  to  small 
punctate  hemorrhages  from  the  congested  and  tortuous 
capillaries.  The  endothelial  cells  are  increased  in  number, 
in  some  places  so  filling  the  cavity  of  the  alveoli  as  to  form 
patches  of  hepatization. 

Pleura. — There  is  fluid  in  both  pleural  cavities,  giving  rise 
to  mechanical  symptoms  and  physical  signs. 

Stomach  and  Intestines. — There  is  either  chronic  conges- 
tion or  a  chronic  catarrhal  inflammation,  giving  rise  to 
characteristic  symptoms. 


// YPER  TKOPH  Y  AND   D If. A  TA  TfON.  1 93 

Liver. — There  is  the  so-called  "  nutmeg  liver,"  its  name 
arising  not  from  any  surface  irregularity,  but  from  the  mot- 
tled color.  The  liver  may  be  large  or  small  or  normal  in 
size.  The  centre  of  each  acinus  is  pigmented  and  depressed  ; 
the  periphery  is  yellowish  from  fatty  degeneration  of  the 
liver-cells.  There  may  be  a  catarrhal  inflammation  of  the 
bile-ducts  with  jaundice ;  there  may  also  be  an  associated 
cirrhosis. 

Pcnto)iewn. — There  is  ascites. 

Kidneys. — There  may  be  either  chronic  congestion  or 
chronic  diffuse  nephritis.  In  the  former  case  the  urine  is 
diminished,  of  increased  specific  gravity,  and  may  contain 
a  little  albumin.  The  quantity  of  urea  is  normal.  There 
are  no  characteristic  clinical  symptoms.  In  the  case  of 
chronic  diffuse  nephritis  the  urine,  which  may  be  either, 
diminished  or  increased  in  quantity,  contains  a  diminished 
amount  of  urea.  There  may  or  may  not  be  albumin  and 
casts.  The  specific  gravity  of  the  urine  is  regularly  low,  be- 
ing about  loio.  This  form  of  nephritis  is  apt  to  give 
symptoms  of  chronic  uraemia. 

The  occurrence  of  nephritis  with  cardiac  dilatation  is  not 
always  the  same. 

1.  In  some  cases  the  dilatation  begins  first  from  valvular 
disease  or  from  any  other  cause  giving  rise  to  venous  con- 
gestions, including  congestion  of  the  kidney,  which  develops 
into  chronic  diffuse  nephritis. 

2.  In  some  cases  there  is  first  developed  a  chronic  diffuse 
nephritis,  by  reason  of  which  toxic  products,  not  being" 
properly  excreted,  collect  in  the  blood,  causing  endarteritis 
and  arterial  spasms.  This  condition  increases  peripheral 
resistance,  which  is  met  by  hypertrophy  of  the  left  ventricle. 
Should  this  compensation  fail,  there  will  be  added  dilata- 
tion of  the  heart. 

3.  In  other  cases  hypertrophy  with  subsequent  dilatation 
and  chronic  diffuse  nephritis  occurs  as  part  of  the  disease 
process  known  as  "  arterio-capillary  fibrosis." 

Skin. — There  may  be  cyanosis.     There  is  a  characteristic 
obliteration  of  the  fine  lines  and  wrinkles  of  the  skin  of  the 
face,  due  to  its  congestion  and   moderate  oedema.     There  is 
13 


194       MANUAL    OF  THE   PRACTICE    OF  MEDKTXE. 

cedema.  first  noticed  in  the  ankles  on  walking  or  standing, 
later  becoming  more  general!)'  distributed. 

Physical  Signs  of  Dilatation. —  i.  Of  Dilatatioi  of  the 
Lift  Heart. — Inspection  shows  a  diffuse  undulatory  pulsa- 
tion over  a  large  area.  There  may  be,  however,  no  pulsa- 
tion visible. 

Pa/patioii. — The  impulse  is  vibratory  and  diffused.  There 
are  cases  in  which  the  pulsation  can  be  seen  but  cannot  be 
felt.  The  apex  beat  is  poorly  defined ;  it  is  diffused,  weak, 
snappy,  or  absent. 

Percussion. — There  is  enlargement  of  cardiac  dulness  both 
vertically  and  transversely.  The  left  border  of  the. area  of 
dulness  is  frequently  found  as  far  as  the  anterior  axillary 
line.  The  upper  border  may  be  at  the  second  rib  ;  the  apex 
may  be  carried  downward  as  far  as  the  seventh  or  eighth 
rib.  The  increase  of  size  is  in  the  same  direction  as  in 
hypertrophy,  but  is  carried  to  a  greater  extent. 

Auscultation. — The  first  sound  at  the  apex  is  short  and 
snappy,  approaching  the  character  of  the  more  purely  valv- 
ular second  sound.  The  second  sound  at  the  base  is  weak 
or  absent.  Both  of  these  signs  are  important  in  making  a 
diagnosis  between  dilatation  and  hypertrophy.  In  some 
cases  the  first  and  second  sounds  are  alike  and  equidistant, 
showing  a  short,  ill-sustained  systole.  This  is  a  serious  sign, 
and  it  is  spoken  of  as  "  embryocardia."  In  many  cases  the 
first  sound  is  replaced  by  the  murmur  of  relative  incompe- 
tence of  the  mitral  valve.  Diagnosis  is  often  impossible 
between  idiopathic  dilatation  with  relative  mitral  incompe- 
tence and  mitral  regurgitation  with  consequent  dilatation. 
The  murmur  of  mitral  stenosis  is  apt  to  disappear  if  dila- 
tation be  established.  The  pulse  of  dilatation  is  weak, 
irregular,  and  of  low  tension.  It  goes  to  pieces  after  any 
physical  exertion. 

If  the  right  ventricle  be  in  good  condition,  it  will  hyper- 
trophy, giving  the  physical  signs  of  this  condition.  Espe- 
cially important  is  the  presence  of  an  accentuated  second 
pulmonary  sound  and  the  absence  of  general  venous  con- 
gestion. 

2.  Of  Dilatation  of  the  Right  Heart. — If  the  right  ventricle 


IIYPEKTKOPIIY  AND   DILATATION.  I95 

dilate,  it  will  become  more  enlarged  to  the  right  and 
downward,  giving  rise  to  a  wavy  impulse  under  the  ensi- 
form  cartilage  and  frequently  in  the  sixth  and  seventh 
spaces  to  the  left  of  the  sternum.     The  accentuated  second 


Fig.  8. — Diagram  showing   compensatory  hypertrophy  of  the  left   ventricle   following 
endarteritis ;  right  heart  normal. 


Fig.  g. — Diagram  showing  failure  and  dilatation  of  the  left  ventricle  (failing  compensa- 
tion), stretching  of  the  mitral  ring  allowing  mitral  regurgitation,  with  hypertrophy  of  the 
right  ventricle  (compensatory) ;  some  pulmonary  congestion,  no  general  venous  congestion. 


Fig.  10. — Diagram  showing  total  failure  of  compensation  :  the  right  ventricle  is  dilated  ; 
tricuspid  leakage  occurs  ;   there  are  both  pulmonary  and  general  venous  congestions. 

pulmonary  sound  is  replaced  by  a  weak  or  absent  second 
sound,  and  symptoms  of  venous  congestions  make  their 
appearance.  If  the  dilatation  be  extreme,  there  may  be 
relative  incompetence  of  the  tricuspid  valve  with  pulsations 
of  the  liver  and  the  jugular  veins. 


196        M.lXr.U.    OF   TJ/E    PRACTICE    OF  MED/CEVE. 

Figures  7-10  show  endarteritis  and  tlic  successive  stages 
of  compensation  (hypertroph}')  and  of  faihng  compensation 
(dilatation). 

ACUTE  ENDOCARDITIS. 

Theoreticalh'  an}-  part  of  the  endocardium  may  be  the 
seat  of  inflammation,  but  practically  the  endothelium  of  the 
valves  and  of  their  immediate  vicinity  is  affected.  In  post- 
natal endocarditis  the  right  heart  is  but  seUlom  involved 
except  in  malignant  cases. 

Etiology. — Endocarditis  does  not  occur  as  a  primary 
disease,  but  always  occurs  in  association  with  other  affec- 
tions. The  affection  may  be  produced  artificially  by  the 
injection  into  the  blood  of  various  pathogenic  micro-organ- 
isms, especially  if  the  valves  be  injured  or  be  the  seat  of 
chronic  inflammation.  The  view  that  endocarditis  is  a 
disease  of  bacterial  infection  is  becoming  more  and  more 
prevalent.  The  most  important  cause  is  acute  articular 
rheumatism,  from  60  to  85  per  cent,  of  all  cases  being 
due  to  this  disease.  Endocarditis  may  complicate  the 
abarticular  form  of  rheumatism  in  children,  in  which  case 
the  primary  cause  is  often  overlooked.  According  to 
Osier,  endocarditis  commonly  follows  chorea :  "  There  is  no 
disease  in  which  post-mortem  acute  endocarditis  has  so 
frequently  been  found."  The  disease  complicates  the 
exanthemata,  especially  scarlet  fever.  It  may  accompany 
any  septic  or  infectous  disease.  It  has  thus  been  found  with 
pneumonia,  erythema,  gonorrhoea,  dysentery,  pyaemia,  and 
puerperal  fever.  Suppurative  infectious  diseases,  however, 
are  more  commonly  the  cause  of  the  malignant  form.  In 
ulcerative  processes  such  as  phthisis,  typhoid  fever,  or 
ulcerating  carcinomata,  slight  inflammations  of  the  endothe- 
hum  are  frequently  found  ;  these  have,  however,  as  a  rule, 
no  clinical  interest. 

Pathology. — The  endocardium  is  a  connective-tissue 
membrane  covered  with  epithelium  and  poorly  supplied 
with  blood-vessels,  hence  its  inflammations  are  of  the 
cellular  rather  than  of  the  exudative  variety.  There  are 
three  grades  of  severity:  (i)  There  is  a  simple  swelling  of 


ACUTE   ENDOCARDITIS.  I97 

the  valve-segments,  their  surface  being  smooth.  (2)  There 
is  swelhng  of  the  valves  with  a  new  cell-growth  in  places, 
so  that  the  surface  is  covered  by  vegetations  composed  of 
granulation-tissue  capped  with  fibrin.  There  may  be  found 
in  the  vegetations  bacteria  of  various  kinds,  but  their 
relation  to  the  disease  process  is  not  known.  The  vegeta- 
tions occur  on  the  valve-segments  at  their  lines  of  maxi- 
mum contact  when  closed.  (3)  The  cell-growth  may  be  so 
excessive  that  the  cells  undergo  necrosis,  causing  ulceration 
or  perforation  of  the  valve.  This  condition  is  more 
common  in  the  malignant  form.  The  mitral  valve  is  the 
one  most  frequently  affected,  next  the  mitral  and  the  aortic, 
more  rarely  the  aortic  valve  alone. 

Effects  of  the  Lesion. —  i.  The  diseased  valve  is  ren- 
dered incompetent  from  stenosis,  from  insufficiency,  or  from 
both. 

2.  The  inflammation  may  extend  to  the  myocardium,  so 
that  it  is  infiltrated  with  cells.  This  inflammation  is  rarely 
severe,  but  it  tends  to  weaken  materially  the  power  of  the 
heart. 

3.  Pieces  of  vegetations  may  become  detached,  enter  the 
blood-current,  and  lodge  in  peripheral  arteries,  causing 
embolism.  The  emboli  are  non-infective  in  simple  endo- 
carditis. 

4.  In  many  cases — estimated  as  one-third  by  some 
authors — pericarditis  occurs,  both  diseases  arising  from  a 
common  etiology.  Extension  of  inflammation  to  the  peri- 
cardium through  the  myocardium  has  occurred,  but  is 
exceedingly  rare. 

5.  Acute  endocarditis  frequently  attacks  a  heart  that  is 
the  seat  of  a  chronic  endocarditis,  this  condition  predispos- 
ing toward  a  new  infection,  and  may  thus  upset  compensation. 

6.  In  acute  cases  it  does  not  make  very  much  difference, 
which  valve  is  affected.  The  chief  question  is,  How  does 
it  affect  the  work  of  the  heart?  As  the  lesion  is  sudden, 
compensation  at  first  is  only  by  increase  of  frequency  and 
possibly  by  increase  of  force;  later  comes  the  question  of 
hypertrophy. 

Symptoms. — The  symptoms  may  be  divided  into  three 


IqS        MAXr.iL    OF   THE   PKACTJCK    OF  MFDICTXE. 

f:^roups :    i.  Symptoms  of  inflammation,    2.  Symptoms  of 
valvular  insufficiency;   3.  Symptoms  of  embolism. 

1.  Syuipto))is  of  Injiauinuitioii. —  Iherc  may  rarely  be  an 
initial  chill.  The  temperature  in  almost  all  cases  becomes 
deviated;  it  ma\'  be  104°  or  105°  in  children,  but  is  rarely 
as  high  in  adults  ;    it  is  often  irregular. 

In  the  majority  of  cases  (75  per  cent.)  there  arc  peculiar 
feelings  referred  to  the  heart.  The  patient  complains  of 
vague  precordial  distress,  a  sense  of  heaviness,  a  feeling  as 
if  the  heart  were  being  squeezed,  etc.  Actual  pain  is  rare. 
When  it  does  occur,  it  is  apt  to  resemble  angina  and  may 
be  referred  to  the  epigastrium.  The  inflammatory  symp- 
toms may  be  obscured  by  those  of  the  disease  to  which  the 
endocarditis  is  secondary. 

2.  Symptoms  of  Valvular  Lisitfficioicy. — The  breathing  is 
rapid,  and  usually  there  is  subjective  dyspncea.  If  the 
myocardium  be  not  involved,  the  pulse  is  rapid  and  the 
heart's  action  is  tumbling  and  tumultuous  from  compensa- 
tory over-action.  There  is  the  subjective  feeling  of  palpita- 
tion. If  there  be  myocarditis,  the  pulse  becomes  rapid  and 
feeble.  There  are  symptoms  of  arterial  anaemia — faintness, 
syncope,  small  feeble  pulse,  and  spots  before  the  eyes. 
There  may  be  symptoms  of  any  of  the  venous  congestions 
mentioned  under  "  dilatation,"  depending  on  the  severity 
and  extent  of  the  lesion. 

3.  Symptoms  of  embolism  may  arise  at  any  time.  Sudden 
lumbar  pain  accompanied  with  albuminuria  or  h?ematuria 
indicates  embolism  of  the  kidney.  Pain  and  swelling  of  the 
spleen  indicate  embolism  of  that  organ.  Embolism  of  the 
brain  is  recognized  by  various  paralyses  depending  upon 
the  location  of  the  embolus,  and  by  disturbances  of  con- 
sciousness. Embolism  of  the  lungs  occurs  only  with 
endocarditis  of  the  right  heart. 

Physical  Signs. — The  most  common  physical  sign  is  a 
"  bellows  murmur,"  systolic,  heard  best  at  the  apex  and 
transmitted  to  the  left,  although  imperfectly.  This  sign  is 
generated  by  mitral  insufficiency.  Other  murmurs  may  be 
heard  according  to  the  valve  affected,  but  diastohc  mur- 
murs are  rare.     The  rhythm  of  the  murmur  is  often  hard 


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ACUTE  ENDOCARDITIS.  I99 

to  determine,  from  the  tumultuous  action  of  the  heart. 
The  presence  of  a  murmur  alone  is  not  diagnostic,  and 
there  are  cases  without  murmurs.  The  association  of  an 
over-acting  tumultuous  heart  and  a  small  feeble  pulse  is  of 
some  diagnostic  valve.  There  may  be  the  physical  signs 
of  dilatation  of  the  left  ventricle  with  accentuation  of  the 
second  pulmonary  sound.  There  may  be  added  the 
physical  signs  of  venous  congestion. 

Course  of  the  Disease. —  i.  Latent  Cases. — The  lesion  is 
slight  and  is  perfectly  compensated.  There  are  no  symp- 
toms. Physical  signs  may  be  present.  In  some  of  these 
cases  the  valve  may  return  to  a  normal  condition.  Em- 
bolism may  occur,  however  mild  the  case. 

2.  Mild  Cases. — There  are  present  inflammatory  symp- 
toms, but  the  circulation  is  not  disturbed  and  there  are  no 
symptoms  of  valvular  inefficiency.  In  severer  cases  there 
may  be  a  tumultuous  action  of  the  heart  and  some 
dyspnoea. 

3.  Sevej^e  cases  result  either  from  an  extensive  lesion, 
from  a  secondary  myocarditis  preventing  compensation,  or 
from  an  acute  endocarditis  engrafted  upon  a  chronic  pro- 
cess, upsetting  compensation.  Very  rarely  there  may  be 
sudden  death  from  excessive  circulatory  derangement. 
There  are  developed  symptoms  of  pulmonary  congestion. 
If  the  right  ventricle  hold  good,  there  will  be  no  general 
venous  congestions.  These,  however,  will  occur  if  the 
right  ventricle  fail  in  its  work. 

Prognosis. — Acute  endocarditis  rarely  proves  fatal 
unless  complicated  by  severe  pericarditis  or  myocarditis. 
A  few  cases  with  healthy  valves  recover,  especially  those 
cases  secondary  to  chorea.  The  liability  to  organic  valvu- 
lar changes  is  great.  The  possibility  of  repeated  attacks, 
especially  in  rheumatic  cases,  must  be  taken  into  considera- 
tion. An  acute  attack  engrafted  upon  a  chronic  endocardi- 
tis may  upset  compensation  and  lead  to  a  fatal  dilatation. 
Sudden  death  is  exceedingly  rare.  The  occurrence  of 
embolism  adds  an  uncertain  element  to  every  case. 

Treatment. — The  old  idea  that  endocarditis  could  be 
prevented  by  curing  rheumatism  early  has  not  been  sus- 


200        MAXCAI.    OF   THE   PK.lCrJCK    OF  MhDICIXE. 

taincd.  Still,  it  is  best  to  treat  every  case  of  rheumatism 
and  chorea  energetically  from  the  very  start.  Patients  with 
rheumatism  should  have  ever}-  source  of  heart  strain 
removed  by  as  nearly  absolute  a  rest  as  possible.  This 
does  not  lessen  the  patient's  liability  to  have  endocarditis, 
but  if  it  does  occur  it  is  much  more  apt  to  be  less  severe, 
less  extensive,  and  less  permanent  in  its  results. 

When  endocarditis  is  once  established,  care  should  be 
taken  not  to  depress  the  heart  by  too  large  doses  of  the 
salicylates. 

Inflammatory  s}'mptoms  are  best  treated  by  strict  bodily 
and  mental  rest,  applications  of  cold  to  the  heart,  and  small 
doses  of  opium. 

The  action  of  the  heart  should  be  controlled.  Stimulants 
should  be  given  if  indicated.  Over-action  of  the  heart  may 
be  treated  by  small  doses  of  aconite  or  of  iodide  of  potas- 
sium, or  by  the  use  of  cold  to  the  precordia.  The  bowels 
should  be  opened  freely,  and  distention  of  the  stomach  is  to 
be  avoided. 

Venous  congestions  should  be  treated  by  heart  stimu- 
lants and  by  depletion  by  diuretics,  diaphoretics,  and 
cathartics.  Blood-letting  may  be  employed  in  selected 
cases. 

The  treatment  of  convalescence  must  be  tonic  and  sup- 
porting, in  order  that  compensation  may  be  made  per- 
manent. 

MALIGNANT  ENDOCARDITIS. 

Synonyms. — Septic.  Ulcerative,  Diphtheritic,  Bacterial, 
Mycotic  endocarditis  ;  Arterial  pya^^mia. 

Etiolog-y. — The  disease  is  secondary  to  a  number  of 
septic  conditions:  (i)  It  may  follow  puerperal  fever  or  any 
septic  condition  of  the  puerperal  state.  (2)  It  follows  septic 
wounds.  "(3)  It  may  complicate  certain  septic  diseases.  Of 
these  diseases,  pneumonia  is  perhaps  the  most  common. 
Cases  have  followed  suppurative  phlebitis  from  ear  disease, 
erysipelas,  diphtheria,  suppurative  p)'lephlebitis,  osteomye- 
litis, dysentery,  abscesses,  and  gonorrhoea.  (4)  In  some 
cases  no  apparent  cause  can  be  found,  but  it  is  supposed 


MALIGNANT  ENDOCA RDJIIS.  20I 

that  germ  infection  occurs  through  unnoticed  cracks  or 
abrasions  of  the  skin  or  the  mucous  membranes. 

The  exciting  cause  of  mah'gnant  endocarditis  is  infection 
of  the  endocardium  by  bacteria.  There  are  a  variety  of  mi- 
cro-organisms capable  of  causing  this  infection,  the  common- 
est being  the  cocci  of  suppuration,  the  coccus  of  erysipelas, 
and  the  pneumococcus.  Infection  of  the  endocardium  by 
bacteria  is  favored  by  its  previous  weakness  or  inflamma- 
tion, three-quarters  of  all  cases  of  endocarditis  occurring  in 
hearts  previously  affected  with  chronic  valvular  disease. 

Lesion. — The  lesion  consists  in  abundant  cell-growth  of 
the  endocardium,  forming  vegetations  capped  with  fibrin, 
the  base  consisting  of  granulation-tissue;  these  vegetations 
contain  colonies  of  bacteria.  The  cells  are  apt  to  become 
necrotic,  so  that  by  their  death  there  are  formed  ulcers 
which  may  perforate  or  erode  the  valve-segments,  the  sep- 
tum, or  even  the  heart  itself,  or  which  may  so  weaken  the 
resisting  power  of  the  valve  that  it  may  become  bulged, 
forming  a  little  aneurysm.  There  may  be  infection  of  the 
deeper  endocardial  layers,  with  the  production  of  small 
abscesses. 

Portions  of  vegetations  containing  bacteria  are  apt  to  be- 
come detached,  enter  the  blood-current,  and  become  emboli 
of  a  distinctly  infective  character.  In  this  way  distinct  sec- 
ondary lesions  are  developed,  (i)  There  may  be  purulent 
inflammation  of  any  of  the  serous  membranes,  meningitis, 
pericarditis,  empyema,  peritonitis,  or  suppurative  inflamma- 
tion of  the  joints.  (2)  There  may  be  suppurative  infarctions 
and  abscesses  of  any  part  of  the  body,  especially  of  the  brain, 
lungs,  kidney,  spleen,  and  liver.  (3)  There  may  be  subcuta- 
neous hemorrhages  from  destruction  of  the  wall  of  a  cuta- 
neous blood-vessel  by  an  infective  embolus.  Ptomaines 
arising  from  the  growth  of  the  bacteria  poison  the  general 
system  and  produce  the  symptoms  of  septicaemia. 

The  location  of  the  inflammation  is  more  widespread  in 
malignant  than  in  simple  endocarditis,  the  right  heart  and 
the  endocardium  lining  the  heart-cavities  being  more  fre- 
quently affected.  In  209  cases  the  aortic  and  mitral  valves 
together  were  affected  in  41  ;  the  aortic  valves  alone,  in  53 ; 


202        MAXr.AL    OF    'fl/E   PRACTICE    OF  MEDICINE. 

the  mitral  valve  alone,  in  yj  \  the  tricuspid  valves,  in  19; 
the  pulmonary  valves,  in  15  ;  the  heart- wall,  in  "i^y,  the  riy^ht 
heart  alone,  in  9.  When  the  endocardium  lining  the  heart- 
cavities  is  affected,  the  most  frequent  situations  are  the  upper 
part  of  the  septum  of  the  left  ventricle  and  the  postero-ex- 
ternal  wall  of  the  left  auricle.  The  spleen  is  large  and  soft. 
Tiie  cells  of  the  kidnc\'s  and  the  liver  show  degenerative 
changes. 

Symptoms. — The  symptoms  may  conveniently  be  divided 
into  three  principal  groups  : 

1.  Symptoms  of  a  Sudden  and  Severe  Heart-lesion. — The 
symptoms  of  this  group  resemble  those  of  simple  endo- 
carditis, but  are  much  more  sudden  and  severe.  There  are 
marked  disturbances  of  circulation,  as  shown  by  venous 
congestion  in  both  the  pulmonary  and  the  systemic  circu- 
lation. The  lesion,  as  a  rule,  is  too  sudden  and  severe  to 
allow  of  any  approach  to  compensation.  There  are  usually 
murmurs  Jieard  according  to  the  valve  affected.  Diastolic 
and  right-heart  murmurs  are  more  common  than  in  simple 
endocarditis.  The  action  of  the  heart  is  often  so  irregular 
and  tumultuous  that  the  rhythm  of  the  murmurs  cannot  be 
determined.  In  some  cases,  especially  when  the  lesion  is 
located  in  the  ventricular  endocardium,  there  ma}^  be  no 
murmur  at  all.  In  three-fourths  of  the  cases  there  are 
present  the  physical  signs  of  antecedent  valvular  disease. 
The  size  of  the  heart  is  not  increased  in  acute  cases,  as  the 
patient  is  apt  to  die  of  sepsis  before  dilatation  can  become 
appreciable ;  but  in  subacute  cases  dilatation  may  become 
evident  and  there  may  be  an  approach  to  a  compensatory 
hypertrophy. 

2.  Symptoms  of  Sepsis. — There  is  a  decided  tendency  for 
the  patient  to  pass  into  the  "  typhoid  state."  There  is  a 
fever  which  is  either  stead\^  or  interrupted  by  marked  re- 
missions. There  are  frequent  chills  followed  by  sudden 
elevation  of  temperature,  its  decline  being  accompanied  by 
sweating  and  prostration.  Repeated  erratic  chills  indicate 
septic  material  in  circulation,  and  they  should  always  cause 
a  diligent  search  to  be  made  for  a  septic  focus  in  some  part 
of  the  body.     It    should    be    remembered,    however,    that 


MALIGNANT  ENDOCARDITIS.  203 

patients  walking  about  in  a  condition  of  fever  are  apt  to 
complain  of  chilly  feelings.  The  chills  of  suppuration  are 
too  erratic  to  be  confounded  with  those  of  malarial  infection. 

3.  Symptoms  of  Infective  Emboli. — Embolic  symptoms  give 
different  clinical  features  according  to  their  localization. 
Emboli  of  the  brain  will  produce  paralyses  of  various  mus- 
cles according  to  the  situation  of  the  embolus,  with  disturb- 
ance of  consciousness.  There  may  be  abscess  of  the  brain 
or  meningitis,  usually  associated  with  furious  delirium.  In 
the  lungs  there  may  be  a  septic  pneumonia  or  an  abscess. 
There  may  be  empyema.  The  spleen  may  become  large 
and  tender  and  may  be  the  seat  of  abscesses.  Abscesses  in 
the  liver  are  accompanied  by  their  usual  symptoms.  Em- 
bolism of  the  kidneys  is  marked  by  lumbar  pain,  by  hema- 
turia, and  possibly  by  the  presence  of  pus  in  the  urine. 
Petechial  rashes  may  resemble  the  eruption  of  certain  cases 
of  typhoid  or  of  cerebro-spinal  meningitis.  In  some  cases,  if 
associated  with  multiple  skin  abscesses,  the  appearance  of 
the  patient  may  be  suggestive  of  hemorrhagic  small-pox. 

The  diagnosis  of  malignant  endocarditis  is  made  by  the 
combination  of  the  three  groups  of  symptoms.  Any  one 
group,  however,  may  be  slight  or  even  latent,  and  any  one 
group  may  predominate  and  give  its  stamp  to  the  disease. 

(i)  If  the  symptoms  of  the  heart-lesion  predominate,  the 
case  will  resemble  simple  endocarditis  or  chronic  endocar- 
ditis with  some  intercurrent  fever,  as  typhoid,  malarial,  etc. 

(2)  If  the  septic  symptoms  predominate,  the  case  may  re- 
semble one  of  typhoid  fever,  surgical  septicaemia,  or  pyae- 
mia. The  disease  may  be  mistaken  for  malarial  fever,  but 
the  chills  are  too  erratic,  the  temperature  does  not  yield  to 
quinine,  and  the  blood-examination  does  not  reveal  the 
malarial  organism.  The  disease  may  also  resemble  acute 
miliary  tuberculosis,  but  a  detailed  examination  of  the  case 
and  the  finding  of  the  bacilli  in  the  sputa  will  render  the 
diagnosis  easy. 

(3)  If  the  embolic  symptoms  predominate,  the  case  may 
resemble  non-infective  embolism  from  simple  endocarditis, 
acute  or  chronic,  or  the  secondary  suppurative  inflammations 
may  resemble  those  of  primary  origin.     Thus  the  case  may 


204        MAXL'AL    OF  THi:    J'K.ICJ/CJ:    OF  MEDICINE. 

be  mistaken  for  meningitis,  for  abscess  of  tlic  brain,  for 
empyema,  etc. 

Duration. — Some  cases  run  an  acute  course  of  about 
two  weeks'  duration.  Death  results  from  the  derange- 
ment of  the  circulation  due  to  the  heart-lesion,  from  sepsis, 
or  from  the  infective  emboli.  Other  cases  run  a  subacute 
course  of  from  ten  to  twelve  weeks,  and  more  rarely  may 
continue  for  six  or  eight  months.  In  these  chronic  cases 
the  infection  is  less  severe,  the  damage  to  the  heart  is  less 
extensive,  and  tliL-rc  is  usually  an  attempt  at  compensation. 
A  few  of  these  chronic  cases  recover,  especially  if  compen- 
sation be  perfected  and  if  embolism  does  not  occur. 

The  prognosis  is  generall}'  bad.  Only  a  {^tw  cases  re- 
cover. These  cases  are  those  which  occur  most  frequently 
after  puerperal  infection  and  which  have  run  a  chronic 
course  without  embolism.  These  cases,  however,  are  left 
with  permanently  disabled  valves. 

Treatment. — The  treatment  is  that  of  both  the  heart  in- 
flammation and  the  septic  condition.  For  the  heart  inflam- 
mation the  treatment  is  that  of  ordinary  endocarditis,  but 
carried  out  more  vigorously,  and  heart  stimulants  are  more 
commonly  indicated. 

There  are  two  ways  by  which  the  septic  condition  may 
be  treated.  One  method  is  by  the  administration  of  qumine 
in  large  doses,  so  that  the  patient  is  kept  thoroughly  cin- 
chonized,  the  unpleasant  effects  of  quinine  being  mitigated 
by  adequate  doses  of  phenacetine  or  sodium  bromide,  of 
which  from  20  to  40  grains  may  be  given  daily.  The 
second  method  consists  in  the  giving  of  alcohol  in  large 
doses,  so  that  the  patient  is  kept  continuousl}'  under  its 
influence. 

The  secondary  suppurations  are  to  be  treated  on  general 
surgical  principles. 

CHRONIC  ENDOCARDITIS;   VALVULAR  DISEASE. 

The  terms  "  chronic  endocarditis  "  and  "  valvular  disease  " 
are  practically  sj-nonymous,  as  it  is  the  endocardium  of  the 
valves  that  is  almost  regularly  affected.     It  is  well  to  dis- 


CHRONIC  ENDOCARDiriS.  20$ 

tinguish  between  two  sets  of  cases,  (i)  chronic  endocarditis 
proper  and  (2)  atheroma. 

Chronic  Endocarditis. 

Patholog-y. — The  lesion  consists  in  the  thickening  of  the 
valve  by  increased  cell-growth  and  the  formation  of  firm 
connective  tissue.  In  this  way  the  valve-segments  become 
contracted,  deformed,  and  insufficient,  producing  either 
stenosis  or  insufficiency,  or  both.  Lime-salts  may  be 
deposited  in  the  thickened  valve,  so  that  it  may  become  a 
dense  calcareous  mass  with  hardly  a  vestige  of  normal 
tissue.  There  may  appear  vegetations  and  ridges  formed 
by  irregular  growth  of  cells  and  connective  tissue,  and  upon 
these  ridges  fibrin  may  be  deposited.  Detachment  of  the 
fibrin  in  masses  will  give  rise  to  emboli  which  are  simple  and 
non-infective  in  this  disease.  The  proliferated  cells  in  the 
valve  may  be  the  seat  of  fatty  degeneration,  producing  opaque 
yellow  spots  frequently  infiltrated  with  salts  of  lime,  or  the 
fatty  cells  may  break  down,  so  that  little  superficial  ulcers 
result.  To  the  combination  of  chronic  connective-tissue 
proliferation  and  fatty  degeneration  of  the  cells  the  name 
"atheroma"  is    applied. 

Etiology. — Chronic  endocarditis  regularly  follows  an 
attack  of  acute  endocarditis  produced  by  any  of  its  causes. 
In  some  cases,  however,  it  is  difficult  to  obtain  a  clear 
clinical  history  of  the  primary  attack.  About  half  the 
cases  have  a  rheumatic  origin.  The  disease  is  most  fre- 
quent in  children  and  young  adults,  and  affects  the  mitral 
valve  with  the  greatest  frequency. 

Symptoms. — (i)  There  are  symptoms  due  directly  to  the 
diseased  valves — aortic  stenosis  or  regurgitation,  or  mitral 
stenosis  or  regurgitation.  Involvement  of  the  valves  of  the 
right  heart  is  exceedingly  rare.  (2)  There  is  developed 
compensatory  hypertrophy ;  or  (3)  a  dilatation  with  various 
venous  congestions  due  to  the  enfeebled  pumping  power  of 
the  heart.     (4)  There  may  be  symptoms  of  embolism. 


206        MAXUAL    OF  THE   PRACTICE    OF  MEDICEXE. 


Atheroma. 

In  this  class  of  cases  the  endocarditis  is  chronic  from  the 
start. 

Pathology. — The  lesion  in  the  valves  is  the  same  as  that 
of  chronic  endocarditis,  but  is  only  part  of  a  tjeneral  set  of 
lesions.  There  is  atiieroma  of  the  aorta,  which  may  be 
dilated.  The  small  arteries  show  the  lesions  of  chronic 
endarteritis ;  their  walls  are  thickened  by  connective 
tissue  and  may  be  infiltrated  with  lime-salts ;  their  lumen  is 
narrowed.  In  the  small  arteries  of  the  brain  miliary 
aneurysms  may  be  formed.  There  may  be  spasm  of  the 
peripheral  arteries.  The  lungs  are  frequently  emphysema- 
tous. The  kidneys  usually  show  the  lesions  of  the  atrophic 
form  of  chronic  diffuse  nephritis.  There  is  frequently 
cirrhosis  of  the  liver.  These  changes  are  spoken  of  under 
the  general  name  "  arterio-capillary  fibrosis,"  and  will  be 
described  with  more  detail  in  a  later  heading.  The  aortic 
valv^es  are  the  favorite  seat  of  the  lesion.  The  mitral  valve 
may  also  be  involved,  but  it  is  rareh'  involved  alone. 

Etiolog-y. — Atheroma  is  a  disease  of  adult  life,  few  cases 
being  seen  before  the  fiftieth  year.  It  is  more  common  in 
men  than  in  women,  and  is  especially  frequent  in  those 
who  lead  a  life  of  exposure,  intemperance,  and  severe 
muscular  strain.  It  is  thus  common  in  longshoremen. 
Alcoholism,  syphilis,  gout,  chronic  rheumatism,  and 
chronic  lead-poisoning  are  cited  as  causes,  and  there  seems 
to  be  a  distinct  family  predisposition  toward  this  series  of 
degenerative  changes. 

The  symptoms  are  in  the  main  those  of  the  first  class, 
but  they  differ  in  the  following  respects  : 

1.  The  lesion  is  not  only  of  the  heart,  but  of  other 
organs  as  well,  more  work  being  thrown  on  the  diseased 
heart  by  reason  of  the  increased  peripheral  resistance  in  the 
aorta  and  the  peripheral  arteries,  and  the  arterial  spasm  due 
to  the  kidney  disease. 

2.  The  lesions  occur  in  late  adult  life,  when  recuperative 
powers  are  on  the  wane  and  when  compensatory  hyper- 
trophy is  imperfect  at  the  best. 


CHRONIC  ENDOCARDn^S.  20/ 

3.  The  patients  are  usually  persons  leading  an  intem- 
perate life  with  severe  muscular  strain,  and  unwilling — 
indeed,  unable — to  take  the  proper  care  of  themselves ;  by 
reason  of  their  condition  of  life  they  are  poor  subjects  for 
compensatory  processes, 

4.  The  lesion  is  progressive.  The  valves  arc  not  only 
deformed,  as  in  the  first  class,  but  tend  to  become  more  and 
more  involved. 

Detailed  symptoms  of  both  sets  of  cases  will  be  given 
under  the  head  of  the  individual  valvular  lesions. 

Mitral  Incompetency. 

Etiology. — Insufficiency  of  the  mitral  valve  results  from 
one  of  three  causes  :  (i)  Contraction  or  shortening  of  the 
valve-segments  from  chronic  endocarditis,  frequently  asso- 
ciated with  changes  in  the  chordae  tendineae  and  with  more 
or  less  narrowing  of  the  orifice.  (2)  Dilatation  of  the  mitral 
ring  from  dilatation  of  the  left  ventricle.  (3)  Defective  mus- 
cular closure  from  myocarditis,  or  from  the  weakening  of 
the   heart  muscle   in  anemia  and   prolonged  fever. 

It  is  important  to  remember  that  mitral  insufficiency  is 
not  always  a  sign  of  chronic  endocarditis,  but  that  the  valve- 
segments  may  be  normal,  the  incompetency  being  "  relative." 

Patholog-y. — As  the  result  of  the  regurgitation  past  the 
mitral  valve,  at  each  systole  of  the  ventricle  the  left  auricle 
receives  blood  from  two  sources — its  regular  supply  from 
the  pulmonary  veins,  and  the  abnormal  supply  from  the  left 
ventricle.  The  auricle  therefore  becomes  dilated  and  to 
some  extent  hypertrophied,  although  the  latter  process  is 
never  well  marked  in  the  case  of  an  auricle.  At  the  time 
of  the  diastole  of  the  left  ventricle  this  abnormal  amount  of 
blood  at  high  pressure  pours  into  it,  over-filling  it.  To  ac- 
commodate this  increased  amount  of  blood  the  ventricle 
must  necessarily  dilate.  Although  at  the  time  of  the  ven- 
tricular systole  only  part  of  the  blood  is  pumped  forward 
in  the  direction  of  the  normal  blood-current,  the  remainder 
being  forced  back  into  the  auricle,  still,  to  get  rid  of  the 
large  supply  of  blood,  the  work  of  the  left  ventricle  becomes 
excessive,  and  therefore  the  ventricle  becomes  hypertrophied. 


208        MAXC-il.    OF  THE   PKACT/CE    OF  MEDICINE. 

Ouiiif^  to  the  over-filliiii^  of  the  auricle  during  diastole,  the 
pulmonary  veins  are  less  readil)-  emptied  ;  the  right  ventri- 
cle expels  its  contents  less  readily,  and  becomes  both  dilated 
and  hypertrophied.  If  the  hj'pertrpphy  of  the  right  ven- 
tricle is  adequate  to  maintain  the  equilibrium  of  the  pul- 
monary circulation,  there  are  no  signs  of  venous  congestions 
in  the  systemic  circulation.  If  compensatory  hypertrophy 
fails,  however,  then  general  venous  congestions  will  ensue. 

Congestion  of  the  pulmonary  vessels  is  not,  as  a  rule,  as 
marked  in  mitral  regurgitation  as  in  mitral  stenosis,  because 
the  back  pressure  is  more  intermittent,  occurring  only  dur- 
ing diastole,  whereas  in  mitral  stenosis  it  is  continuous. 

Cases  of  relative  incompetence  due  to  impaired  nutrition 
of  the  cardiac  wall  or  to  its  dilatation  are  not  usually  well 
compensated.  There  is  apt  to  be  considerable  engorgement 
of  the  pulmonary  vessels,  with  bronchitis  and  often  with 
fairly  profuse  haemoptysis,  and,  from  general  failure  in  the 
power  of  the  right  ventricle  to  work  in  face  of  the  pulmon- 
ary back  pressure,  general  venous  congestions  will  ensue. 

Symptoms. — If  compensation  is  good,  there  may  be  no 
symptoms  noticed  by  the  patient  even  for  years.  There 
may,  however,  be  some  palpitation  and  dyspnoea  on  exer- 
tion, with  a  bluish  tinge  to  the  lips  and  the  ears.  Attacks 
of  bronchitis  or  of  haemoptj^sis  may  occur. 

If  compensation  fails,  the  s}^mptoms  of  pulmonary  en- 
gorgement become  more  marked ;  there  are  palpitation, 
weak  and  irregular  action  of  the  heart,  steady  dyspnoea  with 
developing  orthopnoea,  increase  of  cough  with  bloody  or 
watery  expectoration,  and  dropsy,  first  in  the  feet  and  then 
becoming  more  generally  distributed. 

By  judicious  treatment  compensation  may  again  be  estab- 
lished, and  the  patient  will  recover  from  the  attack.  Subse- 
quent attacks  grow  more  frequent  and  severe,  and  recovery 
from  them  becomes  less  and  less  satisfactory,  until  at  last 
a  permanent  condition  of  general  dropsy  and  venous  con- 
gestions results,  terminating  the  life  of  the  patient.  Sudden 
death  is  exceedingly  rare. 

Physical  Signs. — The  characteristic  murmur  of  mitral 
regurgitation  is  systolic  in  rhythm,  is  heard  with  maximum 


CHRONIC    TUBERCULOSIS. 


209 


intensity  at  the  apex,  and  is  connected  into  the  left  axilla 
and  the  back.  The  murmur, 
which  may  be  loud  enough  to 
be  heard  over  the  whole  of 
the  chest,  is  usually  of  a  blow- 
ing, puffing  character,  but  it 
may  have  a  musical  quality. 
The  character  of  the  mur- 
mur gives  no  indication  of  the 
degree  of  the  insufficiency. 
The  murmur  may  come  and 
go,  and  when  absent  it  may 
frequently  be  reproduced  by 
the  upright  position,  by  deep 

respirations,      or  by     exertion.  Fig.   :.. -Mitral  regurgitation,  showing 

^  ■'  the   area  of  cardiac  dulness,   the  point  or 

There    are    cases  in     which   the  maximum  intensity  ofthe  systolic  murmur, 

1            •,  •          .„    ■  and  the  direction  in  which  it  is  carried. 

murmur  has  its  maximum  in- 
tensity along  the  left  border  of  the  sternum,  at  the  level  of 
the  second  or  third  rib,  where  the  dilated  auricle  approaches 
the  chest-wall.  There  may  also  be  heard  the  rumbling  or 
purring  presystolic  murmur  of  an  associated  mitral  stenosis. 
In  some  cases  the  presystolic  murmur  alone  is  heard,  even  if 
there  be  regurgitation  as  well.  A.  systolic  thrill  is  often 
appreciable  at  the  apex,  but  this  sign  is  not  of  much  diag- 
nostic value. 

The  second  pulmonary  sound  is  accentuated  in  almost 
all  the  cases  where  there  is  compensatory  hypertrophy  of 
the  right  ventricle.  This  sound  is  best  heard  in  the  second 
interspace  to  the  left  of  the  sternum. 

There  are  present  the  ordinary  physical  signs  of  hyper- 
trophy ofthe  left  ventricle,  and  usually  of  the  right  ventricle 
as  well,  or,  in  case  of  failing  compensation,  the  signs  of  their 
dilatation. 

The  pulse  may  show  nothing  abnormal,  or  it  may  be 
irregular.  There  is  no  characteristic  sphygmographic 
tracing. 

The  diagnosis  should  be  made,  not  from  the  presence  of 
the  murmur  alone,  but  from  the  other  signs  as  well — the 
accentuated  pulmonary  second  sound,  the  enlargement  of 

14 


2IO        .U.l.vr.l/.    OF   THE   PKACTICE    OF  MEDICIXE. 

the  heart,  and  the  cHnical  history.  Mitral  incompetency 
should  be  distinguished  in  this  manner  from  those  hasmic 
murmurs  which  are  heard  at  the  apex  of  the  heart,  and  from 
the  so-called  "lung  heart"  or  the  Potain-Rosenbach  mur- 
mur. This  murmur  is  generated  in  the  overlying  lingula 
of  lung  by  the  pressure  of  the  heart's  impulse  against  a 
small  bronchus.  Wx  this  compression  at  each  systole  during 
inspiration  a  swstolic  puffing  sound  is  produced.  This 
sound,  however,  is  not  transmitted  to  the  left,  and  is  heard 
only  during  inspiration. 

The  diagnosis  of  relative  incompetence  due  to  anaemia  or 
to  exhausting  disease  should  be  made  by  a  careful  review 
of  the  case.  The  diagnosis  is  necessary  not  only  in  point 
of  prognosis,  but  also  in  governing  the  treatment. 

Prognosis. — Mitral  incompetency  is  perhaps  the  least 
serious  of  all  the  valvular  affections,  as  it  usually  occurs  in 
young  subjects,  in  whom  compensatory  h\-pertrophy  is  possi- 
ble. The  prognosis  of  relative  incompetence  due  to  anjemia 
or  to  exhausting  disease  is  good  if  the  primar\-  disease  can 
be  cured.  The  cases  which  develop  in  consequence  of  dila- 
tation of  the  left  ventricle  usually  do  badly,  as  the  dilatation 
generally  precludes  all  idea  of  compensation. 

Mitral  Stenosis. 

Etiology. — Mitral  stenosis,  except  for  rare  congenital 
cases,  is  always  the  result  of  valvular  change.  The  affection 
regularly  follows  a  previous  attack  of  endocarditis,  is  usually 
seen  in  early  life,  and  is  more  common  in  women  than  in 
men,  in  the  proportion  of  4  to  i,  because  girls  are  more 
liable  than  boys  to  rheumatism  and  chorea.  The  onset  of 
the  disease  is  often  so  insidious  that  its  origin  cannot  always 
be  determined. 

Pathology. — The  valve-segments  may  be  stiffened  into 
a  rigid  mass,  or  they  may  be  fused  together,  forming  a 
conical  opening,  the  "  funnel-shaped  mitral."  The  orifice  of 
the  valve  may  be  constricted  to  form  a  narrow  slit,  the  "but- 
tonhole mitral,"  or  it  may  be  so  constricted  as  to  admit  only 
the  very  tip  of  the  little  finger. 

A  stenotic  mitral  valve  is  almost  always  incompetent  at 


CHRONIC  ENDOCARDITIS.  21  T 

the  same  time.  The  effect  of  the  stenosis  is  to  impede  free 
passage  of  blood  from  the  left  auricle  into  the  ventricle, 
causing  thus  steady  back  pressure,  from  which  other 
changes  in  the  heart  result. 

The  left  auricle  becomes  much  dilated  and  hypertro- 
phied,  its  muscular  walls  being  increased  from  two  to  four 
times  in  thickness.  The  over-filled  auricle  impedes  the 
outflow  of  blood  from  the  pulmonary  veins ;  pulmonary 
engorgement  results,  being  more  marked  in  this  than  in 
any  other  valvular  affection.  The  majority  of  cases  of  pig- 
ment induration  of  the  lungs  are  due  to  this  condition  of 
engorgement.  Dilatation  and  compensatory  hypertrophy 
of  the  right  ventricle  result,  compensating  for  the  increased 
tension  in  the  pulmonary  vessels  and  equalizing  the  lesser  cir- 
culation. In  course  of  time,  when  the  right  ventricle  fails 
in  maintaining  its  power  and  hypertrophy,  it  will  weaken 
and  dilate,  relative  incompetence  of  the  tricuspid  valve  will 
ensue,  and  general  venous  congestions  will  presage  a  fatal 
issue. 

In  uncomplicated  mitral  stenosis  less  than  the  normal 
amount  of  blood  enters  the  ventricle  to  be  pumped  into  the 
arteries ;  hence  less  work  is  required  of  the  ventricle,  and 
neither  dilatation  nor  hypertrophy  should  occur.  In  cases, 
however,  associated  with  incompetency  of  the  valve,  hyper- 
trophy or  dilatation  of  the  ventricle  occurs.  In  rare  cases 
the  ventricle  may  hypertrophy  without  any  appreciable 
cause.  It  is  supposed  that  increased  peripheral  resistance 
from  general  contraction  of  the  arteries,  caused  by  their 
irritation  by  imperfectly-oxidized  blood  owing  to  pulmo- 
nary congestion  and  engorgement,  might  account  for  these 
cases. 

The  symptoms  of  mitral  stenosis  resemble  those  of 
mitral  regurgitation,  both  conditions  producing  the  same 
results — arterial  anaemia  and  venous  congestions,  first  in  the 
pulmonary  system,  later  in  the  systemic  veins  when  failure 
of  the  right  ventricle  occurs.  S^^mptoms  of  pulmonary 
congestion  are,  however,  more  marked  and  constant  in 
stenosis  than  in  insufficiency.  Children  with  mitral  stenosis 
are  usually  poorly  developed. 


21. 


MAXC'.IL    OF   THE   PRACTICE    OF  MEDICLXE. 


Physical  Signs. — The  cardiac  impulse  is  often  most 
appreciable  in  tlic  region  of  the  lower  sternum  ami  in  the 
fourth"  and  fifth  left  interspaces,  being  caused  b\'  the  hj'per- 
trophied  and  dilated  right  ventricle  approaching  the  chest- 
wall  in  these  situations.  Localized  just  above  and  within 
the  apex  may  be  felt  a  distinct  vibratory  or  "  cat's-purr " 
thrill.  This  thrill  is  presystolic  and  terminates  with  a 
sudden  sharp  shock  synchronous  with  the  cardiac  impulse. 
When  present,  it  is  pathognomonic  of  mitral  stenosis.  Care 
should  be  taken  not  to  mistake  this  apex  thrill  for  a 
diastolic  thrill  at  the  base  due  to  aortic  regurgitation. 
The  nuirmur  of  mitral  stenosis  is  heard  to  the  inner  side 

of  the  apex  beat  over  a  limited 
area  (Fig.  12),  and  is  not  trans- 
mitted in  any  direction.  Its 
rh)thm  is  presystolic,  or,  more 
properly  speaking,  anriatlar- 
systolic,  as  the  murmur  is  pre- 
systolic only  as  regards  the 
ventricular  systole.  The  mur- 
mur is  a  rough,  rolling,  purr- 
ing sound,  represented  by 
pronouncing  "  rup  "  or  "  r-r-r- 
rup,"  having  in  the  latter  case 
a  rolling  drum-beat  character. 
It  may  terminate  abruptly  with 
the  first  sound,  which  is  un- 
usually clear  and  snappy,  or 
there  may  be  a  distinct  interval 
between  the  sounds.  The  murmur  may  consume  a  good 
part  of  the  diastole,  or  it  may  be  heard  only  during  the  latter 
part  of  it.  The  murmur  often  comes  and  goes,  usually  dis- 
appearing if  compensation  fail,  only  to  reappear  should 
compensation  again  be  established.  It  is  often  heard  better 
with  the  ear  than  with  the  stethoscope. 

If  regurgitation  coexist  w^ith  stenosis,  there  will  also  be 
heard  the  murmur  of  the  former  affection  ;  this  murmur  may 
be  so  faint  as  to  be  heard  only  when  the  breath  is  held. 
Valuable  evidence  is  afforded  by  the  second  pulmonary 


Fig.  12. — Mitral  stenosis,  showing  area 
of  cardiac  diilness,  location  of  the  presys- 
tolic murmur,  and  the  area  over  which 
it  is  heard. 


CHRONIC  ENDOCARD/'J'fS. 


213 


sound.  This  sound,  which  is  sharply  accentuated  if  the 
right  ventricle  is  doing  its  work  well,  is  reduplicated  in 
about  one-third  of  all  cases,  and  its  reduplication  is  strong 
presumptive  proof  of  mitral  stenosis.  The  second  aortic 
sound  is  weak,  as  the  amount  of  blood  entering  the  aorta 
is  insufficient  to  raise  its  tension. 

Hypertrophy  and  dilatation  of  the  left  auricle  and  the 
right  heart,  and  possibly  of  the  left  ventricle  as  well,  give 
their  customary  physical  signs. 

The  pulse  of  mitral  stenosis  is  small  as  compared  with  the 
action  of  the  heart,  the  arteries  being  under-filled. 

A  characteristic  of  mitral  stenosis  is  the  occurrence  of 
interpolated  beats  in  the  line  of  the  descent  of  the  pulse- 
wave.  These  interpolated  beats,  which  are  well  seen  in  the 
accompanying  sphygmographic  tracings  (Figs.  13,  14),  are 


Fig.  13. — Sphygmogram  showing  the  interpolated  beats  of  mitral  stenosis. 


Fig.  14. — Sphygmogram  showing  the  interpolated  beats  of  mitral  stenosis. 

little  abortive  systoles,  started  as  extra  contractions  of  the 
overloaded  auricles  and  communicated  thence  to  the  ventri- 
cles. As  their  irregular  systoles  occur  during  the  time  of 
diastole,  when  the  ventricle  is  under-filled  with  blood,  a  dis- 
tinct and  well-marked  pulse-wave  cannot  be  formed. 

Diagnosis. — The  murmur  of  mitral  stenosis  may  be  mis- 
taken for  the  diastolic  murmur  of  aortic  regurgitation,  trans- 
mitted down  to  the  apex  and  heard  there  late  in  the  diastole. 
Examination  at  the  base  of  the  heart  should  reveal  the  max- 


214        J/.lXr.lL    OF   THE   PRACTICE    OF  .UEDICEVE. 

imum  intensity  of  the  aortic  murmur.  The  character  of  the 
pulse,  should  assist  in  the  differential  diagnosis.  The  diag- 
nosis is  more  difficult  if  the  murmur  be  absent.  The  diag- 
nosis must  be  made  upon  the  accentuated  or  reduplicated 
second  pulmonary  sound,  the  weak  second  aortic  sound,  the 
sudden,  snappy  first  sound  at  the  apex,  and  the  physical 
signs  of  enlargement  of  the  right  ventricle. 

The  prognosis  in  mitral  stenosis  is  not  so  good  as  that 
in  mitral  insufficiency,  because  the  back  pressure  of  the 
pulmonary  veins  is  constant  and  not  intermittent,  and  be- 
cause the  force  of  the  left  ventricle  cannot  be  called  into 
requisition  to  aid  in  the  compensation  of  the  lesion. 

Aortic  Regurgitation. 
Etiology. — Insufficiency    of  the    aortic    valves    may   be 
caused  by  the  following  conditions  : 

1 .  Conge7iital  lack  of  development. 

2.  Rupture  of  a  valve-segment.  A  healthy  valve-flap 
may  in  rare  instances  be  caused  by  excessive  strain,  such  as 
heavy  lifting;  or  an  ordinary  strain  may  be  the  means  of 
rupturing  a  valve  that  is  weakened  by  ulcerative  changes. 

3.  Stretching  of  the  aortic  ring,  causing  "  relative  incom- 
petence." This  condition  is  rare,  and  is  seen  only  in  cases 
of  extensive  atheroma  of  the  aorta  with  great  dilatation  just 
above  the  valves. 

4.  Acute  endocarditis.  Aortic  incompetence  does  not  re- 
sult during  an  acute  attack  unless  the  valve  be  eroded  or 
ulcerated.  It  is  more  commonly  seen,  therefore,  in  malig- 
nant endocarditis.  Slow  changes,  however,  may  result  in 
the  shrinkage,  contraction,  and  calcification  of  the  valve, 
causing  it  to  become  incompetent.  Aortic  incompetency 
may  thus  be  seen  in  children  with  antecedent  history  of 
rheumatism  and  acute  endocarditis,  but  it  is  not  so  common 
under  these  circumstances  as  mitral  disease. 

5.  By  far  the  most  common  cause  of  incompetence  is  the 
slow  contraction  due  to  atheroma,  seen  in  able-bodied 
laborers  who  are  subject  to  heavy  muscular  labors  and  who 
over-indulge  in  alcohol.  There  may  be  a  syphilitic 
element    which    of    itself    is    capable    of    causing    arterial 


CHRONIC  £NDOCAA'/)/77S.  21$ 

sclerosis.  Occurring  as  the  result  of  atheroma  there  are 
apt  to  be  found  associated  lesions  in  the  aorta,  arteries, 
kidneys,  liver,  and  lungs,  already  alluded  to  (see  Atheroma, 
page  206). 

Patholog-y.— -As  the  result  of  the  incompetency  of  the 
aortic  valve,  blood  flows  from  the  aorta  back  into  the 
ventricle  during  the  diastole.  The  left  ventricle  then 
receives  blood  from  two  sources — the  normal  supply  from 
the  auricle,  and  the  regurgitated  blood  from  the  aorta. 
The  ventricle  therefore  becomes  greatly  dilated.  Dilatation 
is  all  the  more  extreme  because  the  distention  of  the 
ventricle  occurs  during  diastole,  at  which  time  the  tissues 
are  in  a  relaxed  condition,  and  also  because  the  heart-wall 
is  often  the  seat  of  fatty  degeneration,  as  will  be  shown 
hereafter.  The  increased  labor  of  expelling  this  large 
amount  of  blood,  part  of  which  is  to  roll  back  again,  leads 
to  hypertrophy  of  the  left  ventricle.  This  hypertrophy 
reaches  the  highest  degree  seen  in  any  valvular  disease, 
and  may  produce  a  heart  of  enormous  size  and  weight  (from 
30  to  50  ounces),  to  which  the  name  "  bovine  heart,"  or  cor 
bovimnn,  has  been  applied.  This  is  especially  the  case  in 
children. 

Relative  incompetence  of  the  mitral  valve  is  common  as 
the  result  of  the  dilatation  of  the  left  ventricle ;  when  this 
incompetence  occurs  there  is  apt  to  be  pulmonary  conges- 
tion with  compensatory  hypertrophy  of  the  right  ventricle. 

There  is  a  tendency  in  aortic  regurgitation  for  the  heart 
to  undergo  fatty  or  fibroid  degeneration  from  poor  coronary 
circulation,  either  because  of  the  associated  atheroma  or 
calcification  of  the  coronary  arteries,  diminishing  their  cali- 
bre, or  because  the  coronary  arteries,  by  reason  of  the  dimin- 
ished tension  in  the  aorta,  are  poorly  filled  with  blood. 

Aortic  regurgitation  is  often  associated  with  aortic 
stenosis,  but  regurgitation  alone  is  more  common  than 
stenosis  alone.  Aortic  aneurysm  may  complicate  the 
valvular  disease.  In  advanced  cases  there  may  be  changes 
in  the  cardiac  nerves  and  ganglia  that  may  lead  to  angina 
pectoris. 

Symptoms. — As  long  as  the  hypertrophy  equalizes  the 


2l6       M.IXCAL    OF   THE   PRACTICE    OF  MEDICLXE. 

valvular  defect  there  are  no  characteristic  s\niptoms.  In 
advanced  cases  with  myocardial  degeneration  or  with 
lesions  in  the  aorta  and  coronary  vessels  there  are  apt  to  be 
developed  symptoms  of  arterial  auceniia — headache,  dizzi- 
ness, irritability  of  temper,  faintness  even  to  the  point  of 
syncope,  palpitation,  dyspnoea  on  exertion,  with  the  general 
symptoms  of  anaemia.  There  may  be  dull  aching  pain  in 
the  precordium,  or  else  attacks  of  angina  pectoris.  If  at  any 
time  the  diastole  be  unduly  prolonged,  the  regurgitating 
blood  may  so  empt\-  the  aorta  and  large  vessels  as  to  cause 
sudden  cerebral  anaemia.  Sudden  death  may  occur  under 
these  circumstances,  and  its  possibilit}'  must  always  be 
considered  in  making  the  prognosis.  CEdema  of  the  feet 
and  dyspnoea  with  progressing  symptoms  of  venous  con- 
gestion usher  in  a  fatal  issue,  and  differ  in  no  essential 
features  from  the  venous  congestions  and  heart  failure  of 
other  valvular  lesions. 

The  physical  signs  of  aortic  regurgitation  are  apt  to  be 
clean-cut  and  distinctive.  The  characteristic  murmur,  which 
is  diastolic  in  rhythm,  replacing  the  second  sound,  is 
usually  heard  best  in  the  mid-sternum,  at  the  level  of  the 
third  rib,  and  is  convected  downward  toward  the  lower  end 
of  the  sternum  and  the  apex.  It  may  be  heard  best  in  the 
second  right  interspace  or  at  the  lower  end  of  the  sternum, 
or  even  just  within  the  apex.  If  heard  in  these  latter 
localities,  to  which  it  has  been  convected  downward,  it  may 
closely  resemble  the  presystolic  murmur  of  mitral  stenosi.s. 
Aid  to  diagnosis  in  such  cases  is  afforded  by  the  presence 
of  the  murmur  at  the  base  of  the  heart  as  well,  and  by  the 
other  physical  signs.  Often  the  murmur  is  better  heard 
with  the  ear  than  with  the  stethoscope.  It  may  be  harsh 
and  of  a  "  sawing  "  character,  or  it  may  be  a  soft,  long-drawn 
bruit.     It  is  very  constant  and  reliable. 

The  first  sound  at  the  apex  is  usually  weak,  and  may  be 
replaced  by  the  murmur  of  relative  incompetence  of  the 
mitral  valve. 

The  first  sound  at  the  base  may  be  replaced  by  a  mur- 
mur.   This  may  mean  stenosis  of  the  aortic  valve,  or  merely 


CHRONIC  ENDOCARDfTfS.  21/ 

roughening  of  the  surface  of  the  valve  or  of  the  intima  of 
the  aorta  just  above  the  valve. 

There  may  be  a  distinct  diastolic  thrill  over  the  base  of 
the  heart.  This  thrill  may  be  so  diffused  as  to  reach  the 
apex  and  be  then  mistaken  for  the  thrill  of  mitral  stenosis ; 
but  it  is  not  limited  to  the  apex,  nor  does  it  terminate  with 
the  sharp  shock  of  the  cardiac  impulse,  as  does  the  thrill  of 
mitral  stenosis. 

The  character  of  the  pulse  gives  material  aid  in  diagnosis. 
There  is  visible  pulsation  of  the  peripheral  arteries,  even  in 
the  vessels  in  which  pulsation  is  not  normally  visible.  The 
arteries  may  appear  tortuous,  straightening  themselves  with 
a  peculiar  jerky  motion  with  each  systole.  There  may  be 
capillary  pulsation  under  the  finger-nails  or  over  any  skin 


Fig.  15. — Sphygmogram  of  aortic  regurgitation. 

area  artificially  reddened  by  friction.  However  common 
this  sign  may  be  in  aortic  regurgitation,  it  is  also  seen  in 
profound  anaemia,  in  neurasthenia,  and  in  conditions  asso- 
ciated with  great  relaxation  of  the  peripheral  arteries,  and 
hence  is  not  in  any  sense  pathognomonic. 

There  may  be  pulsation  in  the  second  right  intercostal 
space  or  in  the  suprasternal  notch  that  may  lead  to  the 
diagnosis  of  aneurysm.  There  may  be  a  diastolic  pulsation 
of  the  liver,  even  if  the  tricuspid  valve  be  competent.  Oph- 
thalmoscopic examination  reveals  visible  pulsation  of  the 
retinal  arteries  of  a  characteristic  jerking  quality. 

There  is  heard  a  to-and-fro  murmur  in  the  femoral  artery. 
On  palpation  the  characteristic  "water-hammer"  or  "  Cor- 
rigan "  pulse  is  felt.  The  pulse  strikes  the  finger  with  a 
sudden  forcible  impulse,  and  then  at  once  collapses,  leaving 
the  artery  empty.  This  is  best  appreciated  at  the  radial 
artery  when  the  hand  is  held  above  the  head.     The  quality' 


2lS        MAXrAL    OF   THE    PRACTICE    OF  MEDICIXE. 


of  the  pulse  is  plainly  reco<;ni/.cd  in   the  spln-i^niooraphic 
tracing  (F'g-  IS)- 

Associated  with  these  characteristic  sions  of  aortic  re- 
gurf^itation  are  those  depending-  upon  the  increased  size 
and  muscular  power  of  the  heart.  There  is  a  wide  forcible 
area  of  cardiac  impulse,  the  apex  beat  often  beings  in  the 
sixth  or  seventh  interspace,  and  being  perhaps  as  far  dis- 
placed as  the  anterior  axillary  line.  There  may  be  bulging 
of  the  precordium  in  children.  This  increase  of  size,  also 
determined  by  percussion,  is  due  to  dilatation  and  hyper- 
trophy of  the  left  heart,  and  possibly  of  the  right  heart  as 
well.  ' 

The  prognosis   in  aortic   regurgitation   is   not  good,  for 

three  reasons:  (i)  As  the 
affection  occurs  usually  in 
elderly  overworked  alcoholic 
subjects  as  a  degenerative 
change  frequently  associated 
with  arterial  and  renal  lesions, 
compensation  is  neither  com- 
plete nor  sustained.  (2)  From 
the  frequent  complication  of 
fatty  degeneration  of  the  heart- 
muscle,  there  is  a  tendency 
to  sudden  or  gradual  heart 
failure.  (3)  There  may  at  any 
Fig.  16— Aortic  ixguigitaiion,  showing  time    bc   a   sudden    over-dis- 

the  area  of  cardiac  dulness,  the  usual  points  .  r      i  j_    •    i 

of  the  maximum   intensity  of  the   diastolic  tCntlOU   of   thC  VeUtncle.   CaUS- 

murmur,   and   the  direction   in   which   it  is  jj^^   Jj-j^   paralvsis,  and   the  Sud- 
carried.  '  '  .  ^ 

den  death  of  the  patient  from 
acute  cerebral  anaemia.  The  liabilit}'  to  sudden  death 
should  always   be   remembered   in  giving  the  prognosis. 

Aortic  Stenosis. 
Etiology. — The  lesion  of  aortic  stenosis  may  be  the  re- 
sult of  chronic  endocarditis  following  an  acute  attack  caus- 
ing thickening  and  rigidity  of  the  valve.  Usually,  however, 
the  disease  occurs  in  old  people  as  an  atheromatous  change, 
and  is  associated  with  some  degree  of  incompetency.     The 


CHRON/C  KNDOCARDfriS.  219 

latter  condition  is  the  more  serious,  and  stamps  the  disease 
with  its  own  characteristics. 

Patholog-y. — The  valve-segments  may  be  simply  adherent 
to  each  other,  or  they  may  be  thickened,  contracted,  or  cal- 
cified. There  may  be  a  tongue  of  fibrin  or  large  vegetations 
projecting  into  the  orifice,  further  obstructing  it.  To  over- 
come the  obstruction  to  the  onward  passage  of  blood  through 
the  aortic  outlet,  more  force  is  required  of  the  left  ventricle. 
It  consequently  hypertrophies.  Usually  there  is  but  little 
dilatation.  The  whole  force  of  the  ventricle  being  thus 
called  into  requisition,  compensation  is  usually  good  and 
the  remaining  parts  of  the  heart  are  not  affected.  It  is  only 
when  the  left  ventricle  begins  to  fail  that  there  is  dilatation 
of  the  auricle,  impeded  pulmonary  circulation,  and  increased 
work  for  the  right  heart. 

Symptonis. — There  are  no  symptoms  characteristic  of 
aortic  stenosis.  The  affection  may  last  for  years  and  be  dis- 
covered finally  by  accidental  examination.  In  advanced 
cases,  where  a  lessened  amount  of  blood  enters  the  aorta 
with  each  systole,  there  may  be  sym.ptoms  of  anaemia,  such 
as  dizziness,  faintness,  and  spots  before  the  eyes.  In  more 
advanced  cases  there  may  be  Cheyne-Stokes  breathing 
during  the  latter  part  of  the  disease.  When  compensation 
fails  the  symptoms  of  pulmonary  and  systemic  congestion 
do  not  differ  in  any  way  from  those  caused  by  other 
valvular  affections. 

Physical  Signs. — The  characteristic  m^urmur  is  systolic, 
heard  best  in  the  second  right  interspace,  and  is  conducted 
upward  along  the  course  of  the  great  vessels.  Such  a 
murmur  is  not  distinctive  of  aortic  stenosis,  as  it  may  be 
caused  as  well  by  simple  roughening  of  the  aortic  valve  or 
of  the  intima  of  the  aorta  above  the  valve,  or  by  anaemia. 
If  due  to  stenosis,  the  murmur  is  frequently  harsher  than 
if  due  to  the  other  causes,  but  even  then  it  may  become 
faint  and  distant  if  the  left  ventricle  begin  to  fail.  The 
second  sound  at  the  aortic  area  is  usually  weak  from 
diminished  blood-pressure  in  the  aorta  at  the  time  of  the 
diastolic  closure  of  the  valve.  This  sign  may  be  of  great 
aid  in  diagnosis.     In  other  cases  the  second  aortic  sound  is 


220        .y.iX[:iL    OF   THE   PKACT/CE    OF  MEDICIXE. 


replaced  by  the  murmur  of  aortic  regurgitation.     There  is 
frequently  at  the  base  a  systolic  thrill  which  may  be  very 

well  marked.  There  are  the 
ordinary  physical  signs  of 
h\-pertrophy  of  the  left  ven- 
tricle, and,  in  the  later  stages, 
of  its  dilatation,  and  with  the 
dilatation  the  enlargement  of 
the  right  heart  from  hyper- 
trophy or  dilatation.  The 
pulse  is  small  in  size,  is  regu- 
lar in  rhythm,  and  may  be 
somewhat  slow. 

Prog-nosis. — In  simple  ste- 
nosis the  prognosis  is  gener- 
ally good,  as  compensation 
is  easily  accomplished  by 
hypertrophy  of  the  left  ven- 
tricle. If  the  stenosis  be  ac- 
companied by  regurgitation,  the  prognosis  will  depend  upon 
the  latter  condition. 


Flo.  17. — Aortic  stenosis,  showing  the 
area  of  cardiac  dulness,  the  point  of  maxi- 
mum intensity  of  the  systolic  murmur  (X), 
and  the  direction  in  which  it  is  carried. 


Tricuspid  Regurgitation. 

This  condition  may  result  as  an  acquired  affection  in 
endocarditis,  especially  in  the  malignant  form. 

Relative  incompetence  is  far  more  common,  and  is  due 
to  dilatation  of  the  right  ventricle  with  stretching  of 
the  tricuspid  ring,  or  to  poor  muscular  contraction  of  the 
ventricle.  It  is  thus  produced  by  a  failing  left  heart,  and 
by  any  cause  producing  obstruction  in  the  pulmonary  cir- 
culation, such  as  emphysema  and  interstitial  pneumonia. 
In  either  case  it  is  a  consequence  of  failure  in  compensation 
of  the  right  ventricle.  When  tricuspid  regurgitation  occurs, 
the  blood  at  the  time  of  systole  regurgitates  from  the  right 
ventricle  into  the  auricle  and  the  veins,  with  the  production 
of  venous  congestions. 

The  physical  sig-ns  of  tricuspid  regurgitation  are — (i) 
A  systolic  murmur,  usually  low  and  soft,  heard  with  maxi- 
mum intensity  at  the  lower  part  of  the  sternum,  and  trans- 


CHRONIC  ENDOCARD/riS.  221 

mitted  to  the  right,  frequently  as  far  as  to  the  axilla.  {2) 
Enlargement  and  fulness  of  the  jugular  veins.  (3)  A 
venous  pulsation  in  the  superficial  veins  of  the  neck,  and 
frequently  a  pulsation  of  the  liver.  This  latter  sign  is  be.st 
made  out  by  bimanual  palpation,  and  should  not  be  con- 
founded with  the  apparent  pulsation  imparted  to  the  liver 
by  an  over-acting  right  ventricle.  (4)  Marked  increase  of 
general  venous   congestions. 

Tricuspid  Stenosis. 

Congenital  cases  of  tricuspid  stenosis  are  not  uncommon. 
The  acquired  form  occasionally  occurs,  usually  associated 
with  lesions  of  the  left  heart,  especially  with  mitral  stenosis. 

As  the  only  means  of  compensation  is  by  hypertrophy 
of  the  relatively  weak  right  auricle,  effectual  compensation 
cannot  occur.  Marked  venous  congestions  with  great 
cyanosis  are  the  inevitable  result. 

The  physical  signs  of  tricuspid  stenosis  are — (i)  A  pre- 
systolic rnurmur  heard  at  the  base  of  the  ensiform  carti- 
lage. (2)  Hypertrophy  and  dilatation  of  the  right  auricle. 
(3)  Occasionally  a  presystolic  thrill  over  the  lower  part  of 
the  sternum. 

Pulmonary  Regurgitation. 

This  affection,  which  is  almost  invariably  the  result  of 
congenital  malformation,  is  exceedingly  rare.  The  regurgi- 
tation of  blood  backward  into  the  right  ventricle  is  followed 
by  great  dilatation,  and  relative  incompetence  of  the  tri- 
cuspid valve  is  very  apt  to  result. 

Compensation  is  necessarily  imperfect,  and  a  fatal  issue  is 
not  long  delayed. 

The  physical  signs  of  pulmonary  regurgitation  are — (i) 
A  diastolic  murmur  heard  in  the  second  left  interspace,  and 
convected  downward  and  to  the  right.  It  is  difficult  to 
differentiate  the  murmur  from  that  of  aortic  regurgitation. 
(2)  Enormous  hypertrophy  and  dilatation  of  the  right  ven- 
tricle. (3)  The  physical  signs  of  the  relative  incompetence 
of  the  tricuspid  valve. 


222        MAXr.lL    OF  THE   rKACTlCE    OF  MEDIChXE. 

Pulmonary  Stenosis. 

This  afifection,  which  is  of  i^^reat  rarity  except  as  the  re- 
sult of  disease  or  of  arrested  development  during  intra-uterine 
life,  is  one  of  the  commonest  forms  of  congenital  malforma- 
tions, and  is  often  associated  with  an  open  foramen  ovale 
or  an  imperfect  interventricular  septum.  As  an  acquired 
disease  it  ma\'  result  from  malignant  endocarditis. 

There  is  considerable  hypertrophy  of  the  right  ventricle, 
with  dilatation,  but  compensation  is  seldom  perfect,  being 
easily  upset  by  intercurrent  pulmonary  affections.  The  dila- 
tation of  the  right  ventricle  allows  of  tricuspid  regurgitation 
(relative  incompetence)  in  the  majority  of  cases. 

The  physical  signs  of  pulmonary  stenosis  are — (i)  A 
systolic  murmur  heard  in  the  second  left  interspace,  and 
convected  a  short  distance  upward  and  to  the  left.  (2) 
A  weak  or  absent  second  pulmonary  sound.  (3)  Marked 
hypertrophy  and  dilatation  of  the  right  heart.  (4)  There 
may  be  the  murmur  of  relative  incompetency  of  the  tri- 
cuspid valve,  with  fulness  and  possibly  pulsation  of  the 
superficial  veins,  especially  those  of  the  neck. 

Treatment  of  Chronic  Valvular  Disease. 

The  treatment  of  chronic  valvular  disease  may  be  divided 
into  that  of  the  stage  of  compensation  and  that  of  its  failure. 

Stage  of  Compensation. — Hjpertroph}^  is  in  itself  com- 
pensatory of  valvular  defects,  and  if  the  circulation  be  main- 
tained by  it  so  that  the  arteries  are  kept  filled  and  the 
venous  flow  is  not  obstructed,  there  is  no  medicinal  treatment 
necessary.  Much  harm  is  done  by  injudiciously  prescribing 
digitalis  whenever  a  murmur  is  heard,  no  regard  being  paid 
to  whether  the  lesion  is  compensated  or  not.  Still,  it  is 
necessary  that  compensation  should  be  maintained.  The 
balance  between  the  available  power  of  the  heart  and  the 
work  required  of  it  may  be  so  delicate  as  to  be  upset  easily 
by  weakness  on  the  one  side  or  by  increase  of  work  on  the 
other.  Should  the  patient  run  down  by  reason  of  old  age, 
sickness,  or  vicious  habits,  the  myocardium  will  become 
degenerated  and  its  power  will  be  weakened,  while,  on  the 


CHRONIC  ENDOCAND/TIS.  223 

contrary,  the  hypertrophy  may  be  inadequate  to  meet  any 
demand  for  increased  work. 

I.  The  patient  slioiild  be  kept  in  good  health.  To  secure 
inteUigent  co-operation  it  may  be  necessary  to  inform  the 
patient  of  the  lesion,  although  it  is  usually  best  to  confide 
in  some  intimate  friend  or  member  of  the  family,  upon  whose 
judgment  reliance  can  be  placed.  The  patient  should 
lead  a  quiet,  orderly,  and  well-regulated  life.  The  diet 
should  be  simple  and  wholesome,  and  all  digestive  errors 
are  to  be  corrected  by  appropriate  measures.  Tobacco,  tea, 
and  stimulants  should  be  avoided.  Turkish  baths  should 
be  eschewed,  and  the  patient  should  not  live  in  too  high  an 
altitude.  Mental  worry,  over-fatigue,  and  severe  bodily 
exposure  should  be  avoided.  As  the  prognosis  of  valvular 
disease  with  compensation  is  much  better  than  was  formerly 
supposed,  and  as  sudden  death  occurs  only  with  aortic  re- 
gurgitation, the  patient,  if  informed  of  his  complaint,  should 
be  so  encouraged  and  stimulated  as  to  dispel  mental  depres- 
sion and  despondency. 

2.  The  work  thrown  on  the  heart  shoidd  be  lessened  as 
much  as  possible.  In  almost  all  cases  enough  exercise 
should  be  taken  to  keep  the  general  health  good.  In  fact, 
the  heart's  power  may  even  be  developed  by  graduated 
exercise.  Oertel  recommends  ascending  hills  of  increasing 
steepness  and  length  until  compensation  is  fully  established. 
At  no  time,  however,  should  exercise  or  work  ever  be 
allowed  to  pass  to  the  point  of  excessive  fatigue,  nor  should 
sudden  violent  exercise  be  permitted.  Mental  excitement 
of  all  kinds  should  be  interdicted. 

The  condition  of  arterial  tension  should  always  be  deter- 
mined. Should  it  be  raised,  pointing  to  increased  periph- 
eral resistance,  it  should  be  reduced  and  kept  reduced. 

The  diet  should  be  simple ;  over-eating  and  drinking  are 
to  be  checked ;  the  bowels  must  be  kept  open  and  diuretics 
be  administered.  These  procedures  may  suffice  without 
the  need  of  drugs.  Should  the  latter  be  indicated,  iodide 
of  potassium  (gr.  x  t.  i.  d.),  chloral  hydrate  (gr.  v  to  vii  t.  i.  d.), 
and  nitroglycerin  (gr.  -^^  q.  3  h.)  are  of  the  greatest  value. 


224        -V.l.Vr.l/.    OF   THE   PKACTICE    OF  MEDICINE. 

Treatment  of  Failing  Compensation. — The  treatment 
naturally  is  to  be  directed  to  fulfil  four  indications  : 

1.  To  lessen  the  work  required  of  the  lie  art. 

[li)  By  rest.  This  of  itself  may  restore  disturbed  com- 
pensation, and  should  be  resorted  to  in  all  serious  cases. 
The  patient  should  be  put  to  bed  and  kept  quiet,  or,  in  less 
severe  cases,  confined  to  the  room. 

(/;)  By  avoidance  of  over-action  of  the  heart  by  emotional 
excitement,  alcohol,  tea,  coffee,  tobacco,  or  sexual  excesses. 

{c)  By  diminishing  peripJicral  arterial  resistance,  should 
any  exist,  by  regulating  the  diet,  by  increasing  elimination 
of  offending  waste  products  by  the  skin,  kidneys,  and 
bowels,  and  by  the  administration  of  potassium  iodide, 
chloral,  or  nitroglycerin. 

2.  To  improve  the  force  of  the  heart.  The  best  drug  for 
this  purpose  is  digitalis.  Digitalis  is  contraindicated  in 
perfectly-balanced  compensatory  hypertrophy.  The  indi- 
cation for  its  use  is  broken  compensation,  no  matter  from 
what  valvular  affection.  When  digitalis  does  good  the 
pulse  becomes  fuller,  more  regular,  and  of  better  tension, 
the  dyspnoea  and  oedema  diminish,  and  the  urine  usually 
increases  in  quantity.  There  are  cases  in  which  it  does 
good  even  if  the  pulse  continues  irregular.  Toxic  effects 
may.  however,  be  produced  by  its  injudicious  administration, 
and  are  shown  by  nausea  and  vomiting.  The  urine  is  reduced 
in  amount.  The  pulse  becomes  irregular,  and  there  may 
be  two  heart-beats  to  one  of  the  pulse,  especially  in  mitral 
stenosis.  The  particular  preparation  of  digitalis  to  be  used 
is  of  no  consequence  if  the  drug  be  good.  Only  as  large 
doses  should  be  given  as  may  be  required;  over-stimulation 
should  be  avoided.  Some  patients  in  serious  conditions 
may  require  large  doses — from  15  to  20  minims  of  the 
tincture  every  three  hours — while  other  cases,  less  aggra- 
vated, do  well  on  from  3  to  4  minims  two  or  three 
times  a  day.  As  a  certain  increase  in  the  rapidity  of  the 
heart  is  one  of  the  methods  of  compensation  for  a  valvular 
lesion,  digitalis  should  not  be  given  blindly  to  reduce  the 
frequency  of  the  pulse  to  normal.     The  proper  administra- 


CIJKONIC  KNDOCANDJ'J'JS..  22$ 

tion   of  digitalis   requires    the   greatest  judgment  and   the 
detailed  watching  of  the  patient. 

In  aortic  regurgitation  digitaHs  may  do  harm  by  unduly 
prolonging  the  diastole,  so  giving  time  for  the  ventricle  to 
become  over-distended.  In  such  cases  opium  in  gr.  j  doses 
three  times  a  day  is  often  of  service. 

Strophanthus  in  the  form  of  the  tincture  (gr.  v  to  viii) 
may  be  employed  instead  of  digitalis.  It  is  often  of 
service  in  steadying  an  intermittently  acting  heart,  but  it  is 
inferior  to  digitalis  in  power. 

Convallaria.  caffeine,  and  adonis  vernalis  are  not  now  so 
extensively  used  as  formerly.  They  may  be  given,  how- 
ever, should  digitalis  disagree  with  the  stomach.  Iron  and 
strychnine  are  often  of  great  value. 

The  timely  administration  of  iron,  with  or  without  arsenic, 
often  restores  tone  to  the  system  and  checks  failing  compen- 
sation. Strychnine  is  of  great  service,  combined  with  digi- 
talis, in  increasing  the  force  of  the  heart.  When  the  pulse 
is  intermittent  and  irregular,  iodide  of  potassium  may  be 
given,  either  alone  or  with  digitalis.  It  is  often  of  the 
utmost  service.  Nitroglycerin  is  a  valuable  heart  tonic  to 
meet  temporary  indications.  It  may  be  combined  with 
digitalis. 

When  the  heart's  action  is  rapid  and  tumultuous,  much 
good  is  done  by  cold  applications  over  the  heart.  When 
the  heart-action  is  weak  and  irregular,  constant  irritation 
over  the  heart  by  a  nitric-acid  issue  is  of  great  service. 

3.  To  diminisJi  the  venous  congestions. 
.  (a)  By  venesection.  In  cases  of  dilatation  from  whatever 
cause,  with  venous  congestions,  cyanosis,  and  dyspnoea, 
much  relief  is  experienced  by  the  withdrawal  of  from  15  to 
25  ounces  of  blood.  Timely  venesection  may  save  the  pa- 
tient's life  in  acute  cases. 

{b)  By  purgation.  This  is  of  service  especially  in  cases 
with  dropsy.  From  ^  ounce  to  i  ]4  ounces  of  Epsom  salt 
may  be  given  in  a  concentrated  form  half  an  hour  before 
breakfast.  The  compound  jalap  powder,  or  elaterium,  or  any 
other  hydrogogue  cathartic  may  be  given,  and  is  usually 
well   borne. 

15 


226        MANUAL    OF   THE   PRACTICE    OF  MEDICEXE. 

[c)  By  diuresis.  For  this  purpose  digitalis,  with  or  with- 
out a  saline  diuretic,  potassium  citrate  or  acetate,  is  most 
efficient.  In  almost  every  case  a  sure  indication  that  digi- 
talis is  doing  good  is  the  increase  in  the  quantity  of  the 
urine. 

Calomel  in  gr.  iij  doses  every  six  hours  for  tliree  or  four 
days  is  often  of  the  greatest  service  in  cardiac  dropsy,  acting 
both  as  a  diuretic  and  a  cathartic.  It  should  be  discontinued 
should  stomatitis  develop. 

A  favorite  combination  is  the  pill  composed  of  a  grain 
each  of  powdered  digitalis,  squills,  and  blue  mass.  Iodide 
of  potassium  in  gr.  x  doses  is  often  an  efficient  diuretic.  If 
the  blood-tension  be  abnormally  high,  diuresis  may  be  in- 
creased by  the  reduction  of  the  tension  by  iodide  of  potas- 
sium, nitroglycerin,  or  chloral  hydrate.  When  the  urine 
is  greatly  diminished,  cups  and  poultices  over  the  kidneys 
often  prove  of  the  utmost  value. 

id)  By  operative  iiiterfereiice.  Serous  accumulations  in 
the  pleural  or  peritoneal  cavities  may  interfere  to  such  an 
extent  with  the  respiration  and  the  heart's  action  that  aspira- 
tion under  the  strictest  antiseptic  precautions  may  be  re- 
sorted to.  Frequenth',  after  tapping  ascitic  fluid,  diuretics 
and  cathartics,  formerly  of  no  avail,  will  succeed  in  prevent- 
ing reaccumulation. 

If  the  oedema  of  the  legs  be  unrelieved  by  depletion 
through  the  bowels  and  kidneys  or  by  elevation  and  band- 
aging of  the  feet  and  legs,  scarification  of  the  skin  may  be 
resorted  to,  or  Southey's  tubes — small  silver  cannulae  with 
tubing  attached — maybe  inserted  under  the  skin;  but  these 
methods  are  recommended  only  in  the  very  severest  cases. 

4.  To  improve  tlie general  conditioi.  While  the  symptoms 
incident  to  the  deranged  circulation  are  being  treated,  every 
attempt  should  be  made  to  support  the  general  health  of 
the  patient  and  to  control  all  symptoms  that  interfere  with 
sleep  or  with  general  nutrition.  The  diet  should  be  simple, 
nutritious,  and  easily  digestible.  Over-distention  of  the 
stomach  by  food  or  by  gas  should  be  avoided.  Iron  and 
general  tonics  should  be  given.  It  is  important  that  the 
patient  should  enjoy  a  restful  sleep  at  night.     For  this  pur- 


ACUTE   MYOCARDrnS.  22/ 

pose  sulphonal,  chloralamide,  or  trional  may  be  given.  In 
milder  cases  Hoffmann's  anodyne,  camphor-water,  valerian, 
or  bromide  of  sodium  may  suffice.  In  aggravated  cases 
of  insomnia  with  dyspnoea  and  restlessness  nothing  acts 
more  pleasantly  than  morphine,  preferably  given  hypoder- 
mically.  Opium  by  the  mouth  may  be  given  to  these 
patients  in  divided  doses  throughout  the  day. 


3.  DISEASES  OF  THE  MYOCARDIUM. 

ACUTE    MYOCARDITIS. 

This  disease  occurs  in  two  forms  : 

1.  Acute  Diffuse  Myocarditis. — This  disease  occurs  in  the 
course  of  infectious  diseases  and  in  septic  processes  of  all 
kinds,  and  seems  to  be  due  to  poisoning  of  the  heart-muscle 
by  bacterial  products.  It  is  best  seen  in  fatal  cases  of  diph- 
theria. It  may  complicate  endocarditis  or  pericarditis. 
The  heart-muscle  is  soft ;  its  color  is  dark  red  with  hemor- 
rhagic points,  or  it  may  be  yellowish-red  or  mottled.  The 
heart-cavities  are  frequently  dilated.  The  muscle-fibres  un- 
dergo granular  degeneration  and  may  become  fatty.  The 
interstitial  fibrous  structure  is  infiltrated  with  round  cells. 
The  left  ventricle  is  more  frequently  involved  than  the  right. 
The  disease  may  terminate  in  complete  recovery  or  in 
chronic  fibroid  myocarditis,  or  it  may  end  in  suppuration. 

2.  Acute  Circumscribed  Myocarditis,  or  Acute  Suppurative 
Myocarditis. — This  form  of  myocarditis  is  due  to  infection 
of  the  heart-muscle  by  suppurative  micro-organisms  which 
arise  from  a  primary  focus  of  suppuration  and  reach  the 
heart  as  emboli.  Examination  reveals  small  scattered  foci 
of  suppuration  in  the  heart,  in  the  form  of  grayish  or  of  yel- 
low spots  or  streaks,  usually  surrounded  by  a  hemor- 
rhagic zone.  They  are  most  common  in  the  anterior  wall 
of  the  left  ventricle  and  in  the  septum,  but  they  may  occur 
in  any  locality.  A  suppurative  focus  may  rupture  into  the 
pericardium,  producing  suppurative  pericarditis,  or  into  the 


228        MAXr.lL    OF   TJIE   PRACTICE    OF  MEDICINE. 

heart-cavities,  produciiif^  malifi^nant  endocarditis,  general 
septica-^mia,  or  suppurative  emboli.  These  complications 
may  occur  without  apparent  rupture.  Aneurx'sm  of  the 
heart  and  rupture  of  its  wall  may  occur.  The  disease  is 
almost  al\va)-s  fatal,  as  the  result  of  the  cardiac  condition  or 
of  the  primary  disease.  Rarely  the  abscesses  become  en- 
capsulated, the  pus  becomes  inspissated,  or  a  calcareous 
nodule  may  remain. 

Symptonis. — The  symptoms  of  both  forms  of  nu'ocar- 
ditis  are  indefinite  and  are  obscured  by  those  of  the 
primary  disease.  There  is,  however,  a  sudden  increase  of 
cardiac  weakness  ;  the  pulse  becomes  rapid,  irregular,  and 
feeble ;  dyspnoea  becomes  marked.  The  heart-cavities 
usually  dilate,  and  may  occasion  grave  disturbances  of  cir- 
culation. Sudden  death  may  occur,  even  in  patients  who 
have  not  been  considered  seriously  ill.  This  termination  is 
especially  seen  in  diphtheria. 

The  physical  signs  are  those  of  weakened  action  of  the 
heart,  and  possibly  some  increase  in  its  size  by  dilatation. 
There  may  be  the  murmur  of  mitral  regurgitation  from 
relative  insufficiency.  The  sounds  are  weak  and  may  be 
equidistant,  giving  "  tick-tack "  sounds  resembling  those 
of  the  fetal  heart.  The  occurrence  of  such  "  embryocardia  " 
is  always  of  serious  import. 

The  prognosis  is  always  grave  except  in  the  lighter 
degrees  of  the  diffuse  form. 

Treatment. — The  patient  should  be  kept  in  absolute  rest. 
Cold  applications  to  the  precordium  seem  to  be  of  service, 
and  alcohol  should  be  administered  freeh'.  Digitalis  does 
not  seem  to  be  of  much  service ;  if  given  in  large  doses  it 
may  be  the  means  of  rupturing  a  heart  abscess. 

CHRONIC   MYOCARDITIS. 

Etiology  and  Synonyms. — This  disease  may  follow  acute 
diffuse  myocarditis  or  areas  of  anaemic  necrosis.  It  is  seen 
in  chronic  poisoning  by  alcohol,  syphilis,  or  gout.  It  may  be 
associated  with  pericarditis  or  endocarditiSc  Its  most  com- 
mon cause,  however,  is  the  narrowing  of  the  coronary  arteries, 
producing  either   low-grade    tissue-changes  from  defective 


CHRONIC   MYOCARDI'nS.  229 

blood-supply,  or  thrombus-formation  resulting  in  infarctions 
which  gradually  become  converted  to  fibroid  areas.  The 
affection  is  thus  commonly  met  with  in  people  of  ad- 
vanced age  who  have  indulged  freely  in  alcohol  and 
high  living,  who  have  had  syphilis,  and  who  have  done 
hard  work.  In  such  patients  renal  disease,  endarteritis, 
and  fibroid  myocarditis  are  usually  associated.  Synonyms  : 
Fibroid  heart ;  Fibroid  myocarditis ;  Chronic  interstitial 
myocarditis. 

Pathology. — The  lesion  may  be  diffuse  or  circumscribed. 
The  parts  most  frequently  affected  are  the  wall  of  the  left 
ventricle,  the  papillary  muscles,  and  the  septum.  The 
affected  areas  are  firm,  cut  with  resistance,  and  are  opaque 
and  grayish  in  appearance.  The  lesion  consists  in  the 
increase  of  connective  tissue  with  atrophy  or  degeneration 
of  the  muscle-fibres.  The  coronary  arteries  generally  show 
obliterating  endarteritis.  The  heart  is  usually  enlarged 
and  hypertrophied.  Localized  fibroid  areas  may  allow  of 
sacculated  dilatation  of  the  heart. 

Symptoms. — In  some  cases  of  chronic  myocarditis  there 
are  no  symptoms,  the  lesion  being  accidentally  found  post- 
mortem. In  other  cases  there  may  be  sudden  death,  which 
may  occur  without  previous  symptoms  of  disease.  In  still 
other  cases  there  are  symptoms  of  weakened  power  of  the 
heart  with  circulatory  disturbances.  Palpitation  and  dysp- 
noea are  common.  There  may  be  attacks  of  angina 
pectoris,  which  may  be  the  only  symptom.  Intermis- 
sions and  inequalities  of  the  pulse  are  common,  and  the 
pulse  is  usually  slow,  being  frequently  reduced  to  40  or  50 
beats  in  the  minute.  There  may  be  sudden  syncope, 
coming  usually  after  exertion,  in  which  attack  the  patient 
may  die.  Attacks  of  coma  resembling  cerebral  hemorrhage 
may  occur  and  may  prove  fatal.  There  may  finally  be  any 
of  the  symptoms  of  a  dilated  heart  with  venous  congestions. 

The  physical  signs  are  uncertain.  The  heart  is  usually 
enlarged  in  size  ;  its  sounds  are  weak. 

Diagnosis. — Aid  is  afforded  by  the  presence  of  the 
arterial  degenerative  changes  of  nephritis  and  by  the 
occurrence  of  symptoms  of  a  failing  heart  without  the  signs 


230        MAXr.lL    OF   rilE   PRACTICE    OF  MFD/CINE. 

of  actual  dilatation  or  \-al\'ular  lesion.  The  diagnosis  from 
fatt\'  degeneration  is  almost  impossible. 

Prognosis. — The  patient  may  live  for  years,  but  death 
may  occur  at  any  time  from  an  attack  of  angina,  of  syn- 
cope, of  coma,  or  without  antecedent  symptoms. 

Treatment. — In  general  terms,  the  treatment  is  that  of 
fatt}'  degeneration.  Iodide  of  potassium  is  indicated  in 
syphilitic  cases.  Heart  stimulants  are  demanded  by  signs 
of  cardiac  weakness.  Alcohol,  strychnine,  and  nitro- 
glycerin are  to  be  employed  for  this  purpose,  as  digitalis  is 
contraindicated  because  of  the  already  increased  blood- 
pressure  in  the  sclerotic  arteries.  The  diet  should  be 
simple ;  the  habits  of  life  are  to  be  well  regulated,  and 
exercise  is  to  be  taken  regularly  and  sparingly,  and  never 
suddenly  nor  to  excess. 

SYPHILITIC  MYOCARDITIS. 
Two  forms  of  syphilitic  myocarditis  are  recognized  : 

1.  A  Diffuse  Fibroid  Myocarditis. — This  variety  cannot  be 
distinguished  from  the  ordinary  form  by  either  physical 
signs  or  clinical  symptoms. 

2.  Giimniata  in  the  Myocardium. — These  gummatous 
tumors  weaken  the  heart-muscle,  causing  symptoms  of 
heart  weakness,  and  may  result  in  sudden  death  or  in 
rupture  of  the  heart.  A  positive  diagnosis  can  be  made 
only  in  cases  where  marked  improvement  follows  the 
administration  of  large  doses  of  potassium  iodide  in  syphi- 
litic subjects  with  heart  weakness. 

DEGENERATION  OP  THE  MYOCARDIUM. 
I.  Anemic  Necrosis,  or  white  infarct,  a  localized  degen- 
eration of  the  myocardium,  occurs  as  the  result  of  the 
occlusion  of  a  coronary  artery  or  of  one  of  its  branches  by 
thrombosis  or  embolism.  Thrombosis  is  favored  by 
sclerosis  and  atheroma  of  the  wall  of  the  vessel.  The 
anterior  coronary  artery  is  usually  the  one  involved,  so  that 
the  resulting  anaemia-necrosis  is  found  in  the  left  ventricle 
or  in  the  septum.  The  patch  is  anaemic,  whitish  or  grayish 
in  color,  and   is   usually  of  an  irregular  wedge  shape.     It 


DEGENERATION  OE   7V/E   MYOCARDIUM.  23 1 

may  soften  and  break  down,  and  may  even  result  in  rupture 
of  the  heart,  or  it  may  undergo  hyaline  degeneration  and 
ultimately  become  sclerotic,  forming  the  lesion  of  fibroid 
myocarditis.  Such  a  blocking  of  the  coronary  artery  is 
one  of  the  common  causes  of  sudden  death,  and  the  lesion 
should  always  be  looked  for  in  these  medico-legai  cases. 
In  other  cases  there  are  angina  pains  with  feebleness  of  the 
heart's  action.  There  may  be  a  series  of  such  attacks,  any 
one  of  which  may  prove  fatal. 

2.  Parenchymatous  degeneration,  or  "cloudy  swelling," 
is  seen  in  the  course  of  infectious  diseases,  especially  diph- 
theria, typhoid,  and  scarlet  fever.  It  may  occur  even  if  the 
temperature  be  but  slightly  elevated.  The  left  ventricle  is 
most  markedly  involved :  its  walls  are  pale,  turbid,  and 
exceedingly  soft  and  flabby ;  its  cavity  is  usually  somewhat 
dilated.  The  muscle-fibres  are  seen  filled  with  numerous 
fine  granules  obscuring  the  striae  and  the  nuclei.  There 
may  be  some  infiltration  of  the  interstitial  connective  tissue 
with  round  cells,  and  the  nuclei  of  the  muscle-cells  are  usu- 
ally swollen  and  multiplied.  The  degeneration  may  merge 
into  fatty  degeneration.  The  symptoms  are  those  of  acute 
diffuse  myocarditis,  and  a  differentiation  from  that  disease 
by  clinical  symptoms  and  physical  signs  is  impossible. 

3.  Fatty  Heart. — The  term  "  fatty  heart "  is  loosely 
applied  to  either  of  two  distinct  conditions,  fatty  infiltration 
and  fatty  degeneration. 

(i)  Fatty  Infiltration  {Cor  Adiposiim). — In  general  obesity 
the  normal  amount  of  fat  covering  the  heart  is  much  in- 
creased ;  bands  of  fatty  tissue  may  extend  between  the  mus- 
cular fibres  even  to  the  endocardium  and  the  papillary  mus- 
cles. The  muscular  fibres  may  be  normal  or  atrophied,  or  they 
may  undergo  pressure-degeneration.  The  heart-wall  is 
weakened  and  may  dilate  or  rupture.  Such  fatty  infiltration 
occurs  with  general  obesity,  usually  between  the  fortieth 
and  seventieth  years,  and  is  more  common  in  men  than  in 
women.  It  may  more  rarely  be  seen  in  the  conditions  of 
old  age  and  cachexia. 

The  symptoms  are  indefinite.  There  is  dyspnoea  on  exer- 
tion, due  either  to  the  general  obesitv  or  to  enfeebled  heart- 


232        MAXUAL    OF   THE   PRACTICE    OF  MEDICEVE. 

power.  The  pulse  is  usually  weak  and  rapid.  There  may- 
be angina  pains.  Sudden  death  may  occur  from  rupture  of 
the  heart. 

The  p/iysicn/  sio)is  are  elicited  with  difficulty  because  of 
the  increased  thickness  of  the  chest-wall.  The  area  of  car- 
diac dulness  ma}-  be  increased  by  the  fatty  deposit.  The 
heart-sounds  are  weak ;  there  may  be  a  .systolic  murmur  at 
the  apex,  from  relative  insufficiency  of  the  mitral  valve. 

The  treatment  is  that  of  general  obesity,  by  regulated  diet 
and  systematic  physical  exercise. 

(2)  Fatty  Dcgoicration. — Etiology. — The  heart  is  very 
subject  to  this  form  of  degeneration.  By  reason  of  its 
incessant  activit}'  the  heart  needs  an  abundant  supply  of 
oxygen,  and  it  is  the  most  susceptible  muscle  in  the  body 
to  show  changes  in  nutrition.  Any  cause,  therefore,  pre- 
venting an  abundant  supply  of  good  blood,  or  preventing 
good  circulation  of  blood  within  the  heart  itself,  will  be 
followed  by  degeneration.  Moreover,  the  heart-muscle  is 
most  susceptible  to  bacterial  and  chemical  poisons. 

{ii)  Failure  of  general  nutrition  in  old  age,  in  cachectic  states, 
and  in  wasting  diseases.  Fatty  degeneration  occurs  in  acute 
and  chronic  anaemia,  and  is  more  common  in  those  who  lead 
a  sedentary  life. 

{b)  Failure  in  local  nutrition.  Fatty  degeneration  com- 
plicates chronic  pericarditis  with  adhesions ;  dilatation  of 
the  heart,  or  heart  weakness  from  any  cause  by  which 
the  circulation  of  blood  in  the  coronary  arteries  is  allowed  to 
become  sluggish  by  reason  of  feeble  contractile  power  of  the 
ventricular  wall ;  aortic  regurgitation,  in  which  the  dimin- 
ished arterial  tension  does  not  allow  of  efficient  filling  of  the 
coronary  arteries.  It  may  occur  in  the  hypertrophied  heart 
of  valvular  disease.  It  is  common  with  disease  of  the  coro- 
nary arteries.  As  this  latter  condition  is  usually  secondary 
to  atheroma  of  the  aorta,  fatty  degeneration  of  the  heart 
should  always  be  suspected  in  old  people  with  atheromatous 
changes  of  the  aorta  and  the  aoi'tic  valves  associated  with  a 
weakly-acting  heart. 

{c)  Poisoning  of  the  heart-muscle.  This  complication  may 
occur  with  severe  infectious   disease,  especially  diphtheria 


DEGENERATION   OF   TI/J:    MYOCARD/UM.  233 

and  typhoid  fever,  and  may  be  associated  with  fatty  degen- 
erations in  other  viscera.  It  is  seen  in  an  intense  form 
after  poisoning  by  phosphorus  or  by  arsenic.  It  may  be 
caused  by  long-continued  intemperance,  or  it  may  occur 
with  diabetes. 

Fatty  degeneration  occurs  more  frequently  in  men  than  in 
women,  and  is  usually  a  disease  of  adult  life  or  of  old  age. 
In  some  cases  no  assignable  cause  can  be  found. 

Pathology. — The  process  may  be  general  or  local.  The 
left  ventricle  is  usually,  however,  affected.  At  first  there 
appear  yellowish  striae  and  points  under  the  endocardium, 
especially  in  the  papillary  muscles  and  the  trabeculae,  the 
remainder  of  the  myocardium  being  healthy.  In  more 
marked  cases,  such  as  are  seen  in  profound  anaemia,  the 
entire  heart  may  be  of  a  light-yellowish  color  and  be  very 
feeble  and  flabby,  the  heart-muscle  often  tearing  easily. 
There  may  be  areas  of  a  brownish  color — the  so-called 
"  brown  atrophy."  This  is  especially  seen  in  cases  asso- 
ciated with  valvular  disease  or  senility.  The  heart-cavi- 
ties may  be  dilated,  and  in  extreme  cases  may  rupture.  Micro- 
scopically, the  muscular  fibres  are  seen  to  be  filled  with 
fatty  granules  and  oil-drops ;  the  striae  and  the  nuclei  are 
indistinct.  In  severe  cases  the  fibres  seem  completely  occu- 
pied by  the  granules.  The  areas  of  brown  atrophy,  when 
present,  show  the  color  to  be  due  to  a  deposit  of  yellow- 
ish-brown pigment  about  the  nuclei. 

Symptoms. — In  some  cases  sudden  death  occurs,  with  or 
without  previous  indications  of  cardiac  trouble.  Such  a 
fatal  event  may  follow  the  giving  of  ether  or  chloroform, 
sudden  mental  shocks  or  emotions,  after  exertion,  or  after 
a  hearty  meal.  In  other  cases  there  are  more  definite 
symptoms. 

Usually  symptoms  of  cardiac  insufficiency  appear.  There 
may  be  dyspnoea  on  exertion,  or  it  may  be  constant.  The  pulse 
is  short  and  unsustained.  Such  a  pulse  may  be  a  constitu- 
tional peculiarity  in  some  persons,  but  is  suspicious  if  met  with 
in  old  people.  The  pulse  may  be  regular  or  irregular,  fre- 
quent or  slow,  falling  at  times  even  to  8  or  10  to  the  min- 
ute.    A  slow  pulse  of  low  tension  is  characteristic  when  it 


234        MAXTAL    O/-'   THE    PRACTICE    OE  MEDICLWE. 

occurs,  but  it  is  rather  rare.  The  pulse  may  become  rapid 
and  irregular,  and  may  "  go  to  pieces "  upon  exertion, 
whereas  the  pulse  of  functional  disease  of  the  heart  becomes 
stronger  and  more  regular  on  exertion. 

Kxtreme  fatt\-  changes,  however,  may  be  consistent  with 
a  full  regular  pulse  and  regular  heart's  action,  pro\-i(.led  dila- 
tation of  the  heart  does  not  occur.  It  seems,  then,  that 
the  symptoms  really  depend  upon  the  supervening  dilata- 
tion. When  dilatation  occurs,  there  arc  the  ordinary  .symp- 
toms of  such  condition.  It  can  usually,  however,  be  differ- 
entiated from  dilatation  from  other  causes  by  attention  to 
the  following  points:  (i)The  heart  is  not  always  much 
increased  in  size.  (2)  The  symptoms  are  more  con- 
stant. (3)  CEdema  and  anasarca  are  exceedingly  uncommon. 
(4)  There  are  frequently  present  symptoms  of  a  certain  diag- 
nostic value.  They  comprise  symptoms  of  syncope,  pseudo- 
apoplectic  and  epileptic  seizures,  and  angina  pectoris. 

The  syncopal  attacks  are  characterized  rather  by  their 
duration  than  by  their  intensity.  There  is  never  entire  loss 
of  consciousness,  but  the  attack  may  continue  with  feeble 
heart-action,  frequently  a  pulse  sinking  to  30  or  40  to  the 
minute,  and  cold,  clammy  skin  for  hours.  Such  an  attack 
in  an  old  person  or  in  one  in  whom  a  sufficient  cause  for 
fatty  degeneration  is  present  is  exceedingly  significant. 

The  pseudo-apoplectic  attacks  are  characterized  by  the  sud- 
den onset  of  coma  with  stertorous  breathing,  often  of  the 
Cheyne-Stokes  variety.  There  may  even  be  a  temporary 
hemiplegia.  Absence  of  raised  arterial  tension  and  of  the 
characteristic  temperature-curve  differentiates  this  condition 
from  cerebral  hemorrhage.  The  attack  is  probably  due  to 
circulatory  disturbances  of  the  brain  from  a  weakly-acting 
heart.  From  such  an  attack  the  patient  may  recover,  but 
he  is  alwaj's  mentally  enfeebled. 

The  epileptiform  attacks  resemble  those  of  petit  vial. 
There  are  convulsive  movements,  which  are  not  usually 
severe.  The  patient  is  partially  unconscious,  not  as  in  epi- 
lepsy, but  more  as  in  syncope.  The  pulse  is  usually  slow, 
often  as  low  as  20,  and  of  low  tension.  There  may  be  men- 
tal delusions  or  mania  followin^r  such  an  attack. 


DEGENERATION  OF   'J'lIE   MYOCARDIUM.  235 

The  angina  attacks  are  identical  with  those  of  the  true 
or  the  false  angina. 

Physical  Signs. — There  are  no  essential  physical  signs 
in  fatty  degeneration.  There  need  be  no  increase  in  the 
size  of  the  heart,  and  no  murmur  unless  from  pre-existing 
valvular  disease.  There  may,  however,  be  evidences  of 
dilatation  consequent  upon  the  fatty  degeneration,  and  a 
systolic  murmur  at  the  apex,  due  to  relative  mitral  insuffi- 
ciency. The  heart's  impulse  is  weak,  vibratory,  or  absent. 
The  first  sound  is  short — a  suspicious  sign  in  old  people ; 
the  sounds  may  be  equidistant,  and  the  gallop  rhythm  may 
be  present.  The  absence  of  physical  signs  adequate  to 
explain  the  symptoms  of  cardiac  inefficiency  is  of  the 
greatest  aid  in  diagnosis. 

Prognosis. — Mild  cases  following  anaemia,  wasting 
diseases,  and  fevers  usually  do  well.  The  symptoms  are 
never  well  marked,  consisting  usually  only  of  a  rapid  weak 
pulse  and  some  little  dyspnoea  on  exertion,  with  a  tendency 
to  syncopal  attacks.  The  heart-muscle  returns  to  a  state 
of  health  when  the  general  health  of  the  patient  improves. 

The  prognosis  of  the  severer  forms  is  bad.  Fatty 
degeneration  occurring  in  a  hypertrophied  heart  with  valvu- 
lar disease  weakens  the  muscular  wall,  allows  of  dilatation, 
and  upsets  compensation.  Sudden  death  may  occur  at  any 
time,  either  unexpectedly,  as  during  an  attack  of  syncope, 
pseudo-apoplexy,  epilepsy,  or  angina,  or  from  rupture  of 
the  heart.  The  patient  may  die  from  heart  weakness 
should  he  be  attacked   with  any  intercurrent  disease. 

Treatment. — The  patient  should  avoid  every  physical  or 
mental  excitement  that  might  tax  the  power  of  the  heart. 
Rest  is  of  the  utmost  importance.  The  diet  should  be 
simple  and  nourishing.  The  stomach  should  not  be  over- 
distended  by  food  or  by  gas.  The  strictest  attention  is  to 
be  paid  to  the  general  health.  Anaemia  should  be  met  with 
iron  tonics  ;  malnutrition,  by  proper  feeding,  cod-liver  oil, 
and  fresh  air.  Wine  with  the  meals  may  be  allowed,  to 
stimulate  digestion. 

Symptoms  of  heart  feebleness  should  be  controlled  by 
heart  stimulants  and  strict  enforcement  of  rest.     Digitalis 


236        MAXr.lL    OF  TJIE   PRACTICE    OF  MEDICI. XE. 

is  often  of  great  service,  but  any  of  the  other  cardiac  tonics 
may  be  employed.  Nitroghxerin  is  to  be  employed  if  the 
tension  of  the  pulse  be  high  from  associated  arterio- 
sclerosis. The  general  management  of  the  case  is  that  of 
valvular  disease  with  broken  compensation.  Angina  attacks 
are  best  relieved  by  amyl  nitrite,  nitroglycerin,  or  mor- 
phine given  subcutaneously,  while  sudden  attacks  of  heart 
failure  require  active  stimulation  by  inhalations  of  amx'l 
nitrite  or  ammonia  or  b\'  h\-podermics  of  ether,  whiskey,  or 
digitalis. 

ANEURYSM  OF  THE  HEART. 

1.  AficjirjsDi  of  a  valve  results  from  weakening  of  the 
valve  by  either  simple  or  malignant  endocarditis.  Aneu- 
rysms of  the  aortic  valve  bulge  into  the  left  ventricle;  those 
of  the  mitral  valve,  into  the  auricle.  The  aortic  valves  are 
most  frequently  affected,  the  anterior  mitral  segment  being 
more  often  involved  than  the  posterior.  Rupture  of  a 
valve-aneurysm  produces  extensive  destruction  and  incom- 
petency. 

2.  Anc7irysni  of  flic  licart-wall  is  preceded  by  weakening 
of  the  wall  by  chronic  myocarditis,  by  endocardial  ulcerations 
of  malignant  endocarditis,  and  by  areas  of  anaemic  necrosis. 
In  rare  cases  aneurysm  of  the  heart-wall  has  followed  stab- 
wounds.  The  usual  situation  of  an  aneurysm  is  in  the  left 
ventricle  near  the  apex.  Aneurysm  of  the  auricles  or  of 
the  right  ventricle  is  rare.  The  aneurysm  may  vary  in  size 
from  that  of  a  nut  to  that  of  the  heart  itself  Its  sac  is 
composed  of  pericardium,  myocardium  (the  muscular  fibres 
of  which  are  often  replaced  by  fibrous  tissue),  and  endocar- 
dium. The  cavity  of  the  aneurysm  is  frequently  occupied 
by  laminated  fibrin.  Rupture  of  the  aneurysm  has  occurred 
in  but  7  out  of  90  cases. 

The  symptoms  are  not  distinctive,  and  a  diagnosis  is 
rarely  made.  There  may  be  near  the  apex  some  localized 
bulging,  which  may  give  an  expansile  pulsation.  If  the 
aneurysm  be  large,  there  may  be  marked  disproportion  be- 
tween its  pulsation  and  the  feeble  pulsation  in  the  peripheral 
arteries. 


RUPTURE    OF   77/E   ///CARV.  237 

The  prognosis  is  exceedingly  grave.  Death  may  result 
from  syncope  or  rupture,  but  more  usually  it  occurs  grad- 
ually from  heart  exhaustion  due  to  the  primary  disease. 

The  treatment  is  that  of  fatty  heart.  Nothing  can  be 
done  directly  for  the  aneurysm. 

RUPTURE  OP    THE    HEART. 

Etiology. — A  degenerated  condition  of  the  myocardium 
must  in  all  cases  precede  rupture  of  the  heart.  Fatty  de- 
generation, especially  of  localized  areas,  is  the  most  frequent 
cause,  occurring  in  "jy  per  cent  of  all  cases,  but  anaemic 
necrosis  following  thrombosis  of  the  coronary  arteries,  fatty 
infiltration,  circumscribed  myocarditis,  broken-down  tumors 
and  gummata,  and  deep  endocardial  ulcerations  and  cardiac 
aneurysms  may  also  lead  to  rupture.  Two-thirds  of  all 
subjects  of  rupture  of  the  heart  are  over  sixty  years  of  age. 
The  rupture  usually  occurs  after  exertion,  but  it  may  occur 
while  the  patient  is  at  rest. 

Pathology. — The  usual  situation  of  the  rupture  is  in  the 
anterior  wall  of  the  left  ventricle,  near  the  apex;  more  rarely 
the  rupture  may  be  situated  in  the  posterior  wall  of  the  left 
ventricle,  in  the  septum,  or  in  the  wall  of  the  right  ventricle. 
The  rupture  is  usually  small,  and  it  may  be  either  direct  or 
indirect. 

Symptoms. — If  the  rupture  be  direct,  the  patient  experi- 
ences agonizing  cardiac  pain,  suffocation,  and  great  appre- 
hension. The  pulse  becomes  rapid  and  feeble ;  the  skin  is 
cold  and  clammy.  Death  may  occur  in  syncope  in  a  few 
minutes  (in  71  per  cent,  of  cases),  or  it  may  be  deferred  for 
several  hours.  In  the  more  protracted  cases  vomiting  and 
purging  may  be  noticed. 

The  prognosis  is  always  fatal. 

The  treatment  is  entirely  prophylactic.  Persons  known 
to  have  degeneration  of  the  myocardium  should  lead  tran- 
quil lives  free  from  every  mental  or  bodily  strain. 


238        .U.-IXC'.IL    OF   THE   PRACTICE    OF  MEDIChXE. 


4.  NEUROSES  OF  THE  HEART. 

PALPITATION. 

The  term  "  palpitation  "  is  applied  to  all  forms  of  abnor- 
mal cardiac  sensations  which  are  unpleasantly  sensible  to 
the  patient.  The  distinctive  features  are  violent  pulsations 
of  an  unpleasant  nature,  usually  with  throbbing  of  the  larger 
arteries.  The  pulse  may  be  rapid  and  over-forcible,  but  it 
may  be  normal  or  even  weak.  Tlie  attack  appears  suddenly, 
lasts  a  few  minutes  or  hours,  and,  while  not  serious,  occa- 
sions considerable  alarm.  Various  neurotic  symptoms — 
flushing  of  the  face,  sweating,  eructation  of  gas,  and  the 
abundant  passage  of  limpid  urine — often  accompany  or  fol- 
low the  attack. 

Palpitation  is  a  pure  neurosis,  which  may,  of  course, 
occur  in  a  health}'  or  a  diseased  heart.  It  is  to  be  distin- 
guished from  the  over-action  of  organic  disease  in  that  it  is 
not  produced  by  exertion — in  fact,  is  often  dispelled  by 
exercise— appears  often  at  night  while  at  rest,  and  is  not 
accompanied  by  dyspncea  or  other  symptoms  of  cardiac 
distress. 

Pathology. — There  is  no  lesion,  but  in  long-continued 
cases  hypertrophy  or  dilatation  may  result. 

Etiolog-y. — The  cause  of  palpitation  of  the  heart  is  a  re- 
flex inhibition  of  the  vagus  action  that  enables  the  accelera- 
tors to  run  away  with  the  heart.  The  affection  is  common 
in  women  and  in  young  adults,  and  is  rarer  in  advanced  age. 
It  occurs  in  weak  and  nervous  conditions,  after  sickness, 
in  hysteria  and  neurasthenia,  in  excitable  subjects,  and  at 
the  climacteric.  It  is  produced  by  unhealthy  occupations 
and  by  vicious  modes  of  life.  It  is  common  with  over-use 
of  tea,  tobacco,  or  coffee.  Flatulent  dyspepsia  is  a  prolific 
cause  of  palpitation,  and  it  may  occur  as  a  reflex  phenom- 
enon from  gastric,  intestinal,  or  ovarian  irritation.  The  effect 
of  emotions  is  well  known.  Palpitation  of  the  heart  is  a 
symptom  of  exophthalmic  goitre. 

The  "  irritable  heart  of  soldiers  "  (DaCosta)  is  a  form  of 


TREMOR    CORDS — fN'J'HRAir'rfKN'J'  ACT/ ON.         239 

palpitation  caused  by  excitemeriL  and  ovcr-cxcrtion,  espe- 
cially if  the  thorax  be  compressed  with  shoulder-straps  ;  this 
condition  is  accompanied  with  some  dyspnoea  on  exertion. 

TREMOR    CORDIS. 

This  condition,  which  is  the  opposite  of  palpitation,  oc- 
curs occasionally  in  youth  and  more  commonly  in  advanced 
life.  It  may  occur  in  healthy  hearts  or  in  those  enfeebled  by 
myocardial  degeneration.  The  attack  comes  without  warn- 
ing; the  heart  "trembles"  or  "flutters,"  while  the  pulse 
sinks  to  a  tremulous  thread.  The  attack  lasts  for  a  few 
seconds  and  terminates  by  a  forcible  cardiac  beat. 

Tremor  cordis  is  almost  always  due  to  flatulence  or  car- 
diac distress,  and  is  not  produced  by  emotions.  There  is  no 
accompanying  faintness,  although  the  attack  occasions  seri- 
ous alarm. 

The  prognosis  is  perfectly  good. 

INTERMITTENT   ACTION. 

Intermittent  action  occurs  whenever  the  heart  misses  a 
beat  from  time  to  time.  Intermittency  may  be  regular  or 
irregular,  habitual  and  constant  or  only  occasional.  It 
usually  occurs  after  meals,  as  an  evidence  of  flatulent  dys- 
pepsia;  it  occurs  after  over-use  of  tea,  coffee,  or  tobacco;  it 
is  common  in  gout,  in  uric-acid  diathesis,  in  nervous  and 
hypochondriacal  conditions,  and  after  bodily  and  mental 
shocks.  A  constantly  intermittent  action  of  the  heart  is 
common  to  many  old  people,  and  is  of  no  great  significance. 

Intermittency  often  occurs  with  fatty  degeneration  of  the 
heart,  and  is  to  be  distinguished  from  reflex  intermittency 
by  getting  the  patient  to  exercise  briskly.  By  such  exer- 
cise the  really  weak  heart  goes  to  pieces,  while  the  healthy 
but  neurotic  heart  clears  up. 

Intermittency  associated  with  organic  disease  of  the  heart 
is  often  of  serious  omen,  indicating  that  the  contraction  of 
the  auricles  is  not  sufficient  to  fill  the  ventricles,  hence  the 
ventricles  wait  until  they  are  properly  filled. 


240      .)/.i.yr.i/   ()/•'  77//-;  PhwcTfcr.  of  mkdicixe. 

TACHYCARDIA. 

A  rapid  pulse  accompanies  many  morbid  conditions,  such 
as  fevers,  exhaustion,  collapse,  emotional  conditions  pro- 
ducing palpitation,  pain,  maniacal  conditions,  and  the  inges- 
tion of  certain  poisons,  as  alcohol,  atropine,  nitroghxerin, 
and  over-doses  of  digitalis.  A  rapid  pulse  is  physiological 
after  exertion  and  in  the  newly-born,  whose  normal  pulse 
ranges  between  120  and  135. 

The  term  "  tachycardia,"  or  "  heart-hurry,"  is  more 
properly  applied  to  a  rapid  heart-action,  often  reaching  200 
or  more  in  the  minute,  tlie  action  being,  moreover,  usually 
feeble.  Its  distinguishing  feature  is  the  very  little  disturb- 
ance it  gives,  in  contradistinction  to  the  rapid  pulse  of  exoph- 


FiG.  iS. — Sphygmogram  from  a  case  of  tachycardia.     Pulse-rate,  175. 

thalmic  goitre,  of  palpitation,  of  exertion,  and  of  cardiac 
failure.  Tachycardia  may  be  due  to  tumors  pressing  on 
the  vagus  trunk  or  to  mitral  stenosis.  In  later  life  it  is  an 
important  sign  of  senile  degeneration,  and  is  an  added  source 
of  danger,  as  the  attack  may  terminate  in  syncope  or  in 
asystole. 

Reflex  tachycardia,  a  pure  neurosis,  may  occur  from  any 
source  of  irritation,  especially  from  gastric  distress,  and  in 
reflex  tachycardia  the  pulse  may  be  fairly  forcible. 

Intcniiittoit  tacJiycardia  is  a  rare  disorder  in  which  heart- 
hurry  comes  in  attacks  at  varying  intervals,  each  attack 
lasting  a  few  hours.  The  pulse  is  rapid  and  weak,  fre- 
quently over  200  to  the  minute,  but  usually  the  distress  to 
the  patient  is  but  slight.  The  cause  for  such  attacks  is  not 
definitely  known.  A  permanent  cure  is  rare,  and  the  dis- 
ease may  terminate  fatally  at  any  time. 


BRACIIYCARDfA  ;    BRADYCARDIA.  24I 

BRACHYCARDIA ;  BRADYCARDIA. 

Two  forms  of  slow  heart  are  recognized — the  false  and 
the  true. 

False  brachycardia,  in  which  the  pulse  is  slow  but  the 
number  of  heart-beats  is  normal,  is  usually  due  to  a  dilating 
heart  with  myocardial  degeneration,  in  which  the  dropped 
beats  are  due  to  weak  or  abortive  systole.  In  some 
cases  false  brachycardia  seems  to  be  due  to  alternating  hemi- 
systoles,  each  ventricle  acting  independently. 

True  brachyca7'dia  occurs  whenever  both  pulse  and  cardiac 
systole  are  abnormally  infrequent. 

Infrequent  pulse  occurs  in  some  people  as  a  constitutional 
peculiarity ;  it  occurs  in  hunger,  and  it  is  frequent  in  the 
puerperal  state.  Pathologically  it  occurs  in  a  number  of 
conditions : 

(i)  In  diseases  of  the  medulla  and  in  compression  of  the 
brain  ;  for  example,  in  basilar  meningitis,  tumors  of  the  brain, 
and  cerebral  hemorrhage.  It  occurs  also  with  diseases  and 
injuries  of  the  cervical  cord. 

(2)  In  degeneration  of  the  heart-muscle.  A  slow  pulse 
in  the  aged  is  highly  significant  of  fatty  heart.  The  pulse 
may  fall  to  even  8  in  the  minute  in  these  cases. 

(3)  After  the  sudden  lowering  of  peripheral  resistance,  as 
by  bleeding  or  by  the  withdrawal  of  effusions  in  the  chest 
or  the  abdomen. 

(4)  After  the  critical  fall  of  temperature  in  acute  fevers, 
especially  in  pneumonia,  typhoid  fever,  erysipelas,  and  acute 
articular  rheumatism. 

(5)  In  poisoning  by  digitalis,  alcohol,  aconite,  or  lead. 
Infrequent  pulse  occurs  regularly  with  jaundice.  It  is  com- 
mon in  uraemia.  The  poison  may  be  from  auto-intoxica- 
tion following  digestive  disturbances — a  very  common  cause 
for  brachycardia.  Thus  it  is  frequently  observed  with  ulcer, 
cancer,  or  dilatation  of  the  stomach. 

(6)  Conditions  of  asphyxia. 

(7)  Various  conditions  of  melancholia. 
Brachycardia  is  most  common  with  advanced  life.     The 

affection  is  usually  of  serious  import,  as  in  senile  hearts  it  is 

16 


242        MAXr.lL    OF   TJIK    PKACTICE    OF  MEDICIXE. 

very  often   dependent   upon   dilatation  and   nn'ocardial   de- 
generation. 

The  treatment  is  that  of  the  underlying  cause. 

ANGINA  PECTORIS. 

Definition  and  Synonyms. — .Vngina  pectoris  is  a  disease 
characterized  by  severe  pain  over  the  heart,  by  a  sense  of 
impending'  death,  and  in  severe  cases  by  disturbances  in  the 
action  of  the  heart.  Sy)iony))is  :  Stenocardia ;  Breast-pang ; 
Neuralgia  of  the  heart. 

Etiology. — The  disease,  which  is  one  of  adult  life,  and 
usually  of  the  higher  classes,  attacks  men  in  over  80  per 
cent,  of  all  the  cases.  The  exciting  cause  of  an  attack  may 
be  either  exertion,  external  cold,  indigestion,  or  constipa- 
tion, subsequent  attacks  becoming  more  and  more  easily 
provoked.  In  some  cases  no  exciting  cause  can  be  dis- 
covered. 

Lesion. — No  one  lesion  is  constant.  Ossification  or 
inflammation  of  the  coronary  arteries  is  commonly  found. 
Fatty  heart,  arterial  sclerosis  leading  to  high  arterial  ten- 
sion, atheroma  of  the  aorta  or  of  the  aortic  valves,  fibroid 
myocarditis,  and  chronic  inflammation  of  the  coronary 
plexus  are  also  among  the  pathological  findings.  In  some 
rare  cases  no  lesion  is  discoverable. 

The  nature  of  the  disease  is  not  well  known.  The  best 
explanation  seems  to  be  that  a  sudden  high  tension  occurs 
in  the  arteries,  causing  a  spasm  of  the  heart  in  its  efforts  to 
overcome  the  resistance.  The  same  spasm  occurs  in  an 
over-filled  bladder  or  stomach  when  its  contents  cannot 
easily  be  expelled,  causing  often  agonizing  pain.  As  a 
matter  of  fact,  extreme  degrees  of  arterial  tension  occur  in 
96  per  cent,  of  all  cases  of  angina  pectoris  during  the 
attack.  In  the  4  per  cent,  of  cases  in  which  the  tension 
is  not  raised  no  explanation  can  be  given.  There  being 
in  almost  all  cases  some  form  of  cardiac  lesion,  angina 
pectoris  affords  the  strongest  presumptive  proof  of  organic 
disease. 

Symptoms. — The  symptoms  occur  in  attacks  lasting 
from  a  few  seconds  to  half  an  hour.     One  or  two  minutes 


ANGINA   PECTORIS.  243 

is  the  average  duration.     The  severer  attacks  occur  at  night. 
Each  attack  is  attended  by  three  cardinal  symptoms  : 

(i)  Pain  over  the  heart  is  exceedingly  severe;  it  is  neur- 
algic in  character,  with  a  sense  of  constriction.  The  pains 
may  radiate  up  the  neck  and  down  the  left  arm  and  hand,  or 
they  may  extend  to  the  back.  The  face  is  cold,  ashen-pale, 
and  clammy ;  the  expression  is  anxious ;  there  may  be 
general  sweating.  The  patient  immobilizes  himself  from 
pain.  With  the  pain  there  may  be  a  feeling  of  numbness 
or  coldness  in  the  fingers. 

(2)  Dread  of  impending  death  coexists  with  the  pain  in 
an  equal  degree.  After  the  attack  is  over  the  patient  fre- 
quently exclaims  that  if  the  pain  had  lasted  a  minute  longer 
he  would  have  died.  In  attacks  cut  short  by  the  use  of 
drugs  the  sense  of  impending  death  may  not  be  noted.  In 
mild  degrees  the  patient  may  complain  only  of  uneasiness 
and  general  apprehension. 

(3)  Disturbance  in  the  heaj^fs  action  occurs  in  almost  all 
attacks.  The  pulse  becomes  rapid  and  irregular,  and  in  96 
per  cent,  of  cases  is  of  extremely  high  tension.  In  some 
cases,  however,  the  pulse  may  be  uniform  and  but  slightly 
altered. 

There  may  be  considerable  dyspnoea,  and  during  the 
attack  there  may  be  a  vehement  desire  to  pass  urine, 
although  the  bladder  be  empty. 

The  attack  may  terminate  in  recovery,  usually  with  the 
eructation  of  gas,  with  vomiting,  or  with  the  passage  of  a 
large  quantity  of  limpid  urine;  or  the  patient  may  pass  into 
syncope,  from  which  he  may  or  may  not  recover. 

Some  patients  who  have  had  angina  suffer  from  time  to 
time  from  attacks  of  faintness  without  either  pain  or  dread. 
This  condition  is  not  really  angina,  but  is  equally  as 
serious. 

There  may  be  but  one  attack  of  angina,  or  there  may  be 
a  number  of  attacks  at  irregular  intervals  of  weeks,  months, 
or  years. 

Between  the  attacks  the  disease  itself  gives  no  symptoms, 
although  the  underlying  cardiac  lesions  present  their 
ordinary  clinical  symptoms  and  physical  signs. 


244        MA  XL' A  L    OF  TJIE   PRACTICE    OF  MEDICINE. 

The  prognosis  is  bad.  The  patient  may  die  in  many  of 
the  attacks,  some  patients  not  surviving  the  very  first.  Re- 
curring attacks,  as  a  rule,  become  more  frequent  and  more 
severe,  although  it  is  possible  for  the  attacks  at  any  time  to 
cease  recurring.  Much  can  be  done  by  judicious  treatment. 
The  prognosis  is  best  in  cases  in  which  the  attacks  are 
induced  by  a  preventable  cause.  The  disease  often  runs  a 
protracted  course,  and  is  not  so  serious  if  associated  with 
aortic  disease. 

Treatment. — During  an  Attack. — Treatment  is  directed 
toward  the  blood-tension  and  the  pain.  If  the  arterial 
tension  be  increased,  amyl  nitrite  should  at  once  be  given 
by  inhalation,  from  2  to  5  drops  being  placed  in  cotton  or 
on  a  handkerchief  and  applied  to  the  nose.  Patients 
subject  to  attacks  of  angina  pectoris  should  carry  with 
them  constantly  the  pearls  of  amyl  nitrite,  and  should  use 
them  at  the  first  indication  of  an  attack.  Usually  this 
treatment  cuts  short  an  attack,  but  it  may  fail.  If  relief  is 
not  afforded  in  a  minute  or  two  by  amyl  nitrite,  chloroform 
should  be  given,  a  few  inhalations  often  affording  prompt 
relief  In  some  cases  a  hypodermic  injection  of  morphine 
must  be  resorted  to ;  its  action  is  rendered  more  efficient 
by  a  hot  bath.  In  case  the  arterial  tension  be  not  increased, 
amyl  nitrite  does  not  do  much  good,  and  the  treatment 
consists  chiefly  in  morphine  combined  with  inhalations  of 
chloroform. 

Between  the  Attacks. — The  general  health  should  be 
cared  for  in  every  possible  way.  Excitement  and  sudden 
or  severe  muscular  effort  should  be  avoided.  Tobacco  and 
stimulants  are  prohibited.  Exciting  causes  of  attacks 
should  be  found  and  prevented.  If  the  blood-tension  is 
high  between  the  attacks,  it  should  be  reduced  by  regula- 
tion of  the  diet  and  the  action  of  the  kidneys  and  the 
bowels  and  by  the  use  of  drugs.  For  this  purpose  nitro- 
glycerin may  be  given  in  gr.  y^  doses,  at  first  three  times  a 
day,  the  do.se  being  increased  gradually  until  the  patient 
complains  of  flushing  or  of  headache. 

Prolonged  use  of  iodide  of  potassium  is  often  followed 
by  good  results.     From  10  to  20  grains,  three  times  a  day. 


PSKUDO-ANG/NA.  245 

may  be  given  for  years,  the  close  being  omitted  from  time 
to  time  or  being  replaced  by  doses  of  nitroglycerin  to  avoid 
iodism.  There  may  be  good  results  obtained  by  combining 
chloral  hydrate  in  5-  or  7-grain  doses  with  the  iodide. 

PSEUDO-ANGINA. 

Etiology. — Women  are  niore  frequently  affected  with 
pseudo-angina  than  are  men.  The  disease  is  most  common 
in  the  nervous  and  neurasthenic,  and  is  apt  to  be  associated 
with  other  nervous  and  vaso-motor  phenomena.  It  may 
occur  at  any  age.  It  is  common  at  the  menopause,  and  may 
occur  with  especial  frequency  at  the  monthly  sickness.  The 
attacks  may  arise  spontaneously,  or  they  "may  be  precipi- 
tated by  worry  or  by  disturbing  emotions.  In  some  cases 
there  is  a  distant  reflex  origin. 

Pathology. — Pseudo-angina  is  a  pure  neurosis,  and  there 
is  no  essential  lesion. 

Symptoms. — The  disease  comes  in  attacks  which  last 
for  minutes,  days,  or  even  for  weeks.  If  the  attack  be  pro- 
longed the  symptoms  are  remittent.  The  average  duration 
is  one  or  two  hours,  being  longer  than  in  true  angina. 
The  attacks,  which  may  recur  with  a  certain  periodicity,  are 
usually  more  frequent  than  in  true  angina.  The  symptoms 
of  an  attack  somewhat  resemble  those  of  true  angina.  There 
is  pain  over  the  heart,  which,  however,  is  less  severe,  more 
diffused,  and  often  is  accompanied  with  precordial  tender- 
ness. The  patient  does  not  immobilize  himself  as  in  angina, 
but  is  agitated  and  anxious.  There  is  not  the  same  dread 
of  impending  death,  although  the  patient  is  apprehensive. 
The  heart's  action  is  either  feeble  and  irregular  or  tumult- 
uous. The  arterial  tension  is  not  increased.  The  breath- 
ing is  rapid  and  oppressed.  Vomiting  and  pain  over  the 
stomach  are  common  toward  the  close  of  protracted  attacks. 
There  may  be  various  hysterical  or  neurotic  symptoms  dur- 
ing and  between  the  attacks. 

The  diagnosis  is  chiefly  to  be  made  from  true  angina. 
The  chief  points  of  diagnosis  have  already  been  given.  The 
absence  of  arterial  or  cardiac  lesions  would  be  of  importance 
in  excluding  the  true  angina.     There  are,  however,  difficult 


246        J/.l.Vr.-lL    OF   THE   PRACTICE    OF  MEDICIXF. 

cases  of  combined  hysteria,  aortic  valvular  disease,  and  an- 
gina pains  in  \-oung  women,  in  which  an  absolute  diagnosis 
cannot  be  made. 

The  prog-nosis  is  perfectly  good  both  for  life  and  for 
recovery. 

Treatment. — During  the  attack  the  action  of  the  heart 
should  be  regulated  ;  if  the  attack  be  prolonged,  sedatives 
and  anti-neuralgic  remedies  may  be  employed,  such  as 
phenacetine,  bromide  of  sodium,  and  camphor  or  cannabis 
indica.  As  the  arterial  tension  is  not  increased,  amyl 
nitrite,  nitroglycerin,  and  similarly  acting  drugs  are  not 
indicated.  Between  the  attacks  treatment  should  be  directed 
toward  the  general  health  and  the  underlying  nervous 
condition. 

EXOPHTHALMIC    GOITRE. 

Definition  and  Synonyms. — Exophthalmic  goitre  is  a 
disease  characterized  by  enlargement  of  the  thyroid  gland, 
protrusion  of  the  eyeballs,  and  tachycardia,  together  with 
various  nervous  phenomena.  The  disease  was  first  de- 
scribed in  1786  by  Parry,  but  a  complete  description  was 
first  given  in  1835  by  Graves  of  Dublin,  and  in  1840  by 
Basedow  of  Germany.  Syno)iyuis :  Graves'  disease  ;  Base- 
dow's disease. 

Etiology. — While  no  age  is  exempt,  exophthalmic  goitre 
is  most  common  between  the  ages  of  fifteen  and  thirty-five. 
It  occurs  in  women  in  the  proportion  of  5  to  i.  When  it 
occurs  in  men  it  seems  to  run  a  more  severe  course.  It  is 
most  common  in  anaemic  nervous  people,  and  ,may  run  in 
families  predisposed  to  nervous  ailments.  It  may  follow 
a  blow,  a  shock,  or  a  fall.  It  may  occur  after  preg- 
nancy, although  when  pregnancy  occurs  in  a  patient  af- 
fected by  the  disease,  recovery  more  or  less  complete  may 
ensue. 

Pathology. — The  nature  of  the  disease  is  unknown.  A 
supposed  lesion  has  been  sought  for  in  the  sympathetic 
nervous  system,  but  changes  in  the  nerves  and  the  ganglia 
are  neither  constant  nor  peculiar.  The  disease  can  be  re- 
produced   in   dogs   by  destruction  of  the  restiform  bodies, 


ExonrniALMic  gui'J're.  247 

and  a  case  has  been  reported  in  which  hemorrhages  were 
found  in  the  floor  of  the  fourth  ventricle.  The  theory  first 
advanced  by  Moebius  in  1886  is  now  generally  accejjted  : 
that  the  symptoms  are  due  to  an  excess  of  thyroid  poison 
acting  directly  on  the  vasomotor,  nervous,  and  muscular 
systems.  The  resemblance  between  the  symptoms  of  ex- 
ophthalmic goitre  and  those  produced  by  overdosing  by 
thyroid  extract,  and  the  contrast  between  the  symptoms 
and  those  of  myxoedema,  seem  to  attest  the  correctness  of 
this  theory. 

The  symptoms  of  exophthalmic  goitre  may  be  divided 
into  four  groups  : 

1.  Heart  Symptoms. — The  heart's  action  becomes  rapid, 
running  frequently  as  high  as  120  to  140,  or  even  200,  beats 
in  the  minute.  The  rapidity  is  largely  controlled  by  the 
conditions  of  rest  and  exertion.  The  action  of  the  heart  is 
usually  forceful  and  accompanied  by  a  feeling  of  palpitation, 
but  both  these  latter  symptoms  may  be  absent.  The  tachy- 
cardia is  usually  the  first  symptom  observed,  and,  in  fact, 
the  disease  may  stop  here,  with  this  as  its  only  symptom. 
There  is  usually  marked  pulsation  of  the  carotids,  and  there 
may  be  a  capillary  pulsation.  In  long-continued  cases  there 
may  be  hypertrophy  of  the  heart,  which  may  in  debilitated 
subjects  merge  into  dilatation.  Soft  systolic  murmurs  at  the 
base  are  common ;  they  may  be  heard  at  the  apex  as  well. 

2.  Exophthalmos  usually  follows  the  tachycardia.  The 
eyeball  is  protruded,  and  the  eyelids  do  not  cover  the  scler- 
otics,  leaving  a  rim  of  white  above  and  below  the  cornea, 
giving  the  patient  a  peculiar  startled  look.  The  protrusion 
may  be  extreme,  so  that  the  eye  is  dislocated  from  its 
socket.  There  is  a  lack  of  synchronism  between  the  action 
of  the  eyeball  and  that  of  the  upper  eyelid,  so  that  when 
the  eyeball  is  moved  downward  the  lid  does  not  follow  it  as 
in  health.  This  is  known  as  "  Graefe's  symptom."  The 
upper  eyelid  may  be  so  retracted  that  it  is  retained  near  the 
bony  wall  of  the  orbit,  and  to  this  condition  is  given  the 
name  of  "  Stellwag's  symptom."  The  pupils  and  the  optic 
nerves  are  usually  healthy,  but  pulsation  of  the  retinal  ves- 
sels is  common.    Exophthalmos  may  be  absent  in  some  cases. 


248        M.l.yr.ll.    OF   THE   PA'ACr/CE    OE  MEDICIXE. 

3.  Goitre  develops  with  the  exophthalmos.  It  may  be 
general  or  in  only  one  lobe,  and  the  enlargement  is  rarely 
so  extreme  as  in  simple  goitre.  The  gland  is  soft  and 
pulsating  at  first,  becoming  firmer  and  harder  in  protracted 
cases.  There  is  usually  a  thrill  felt  on  palpation.  On 
auscultation  ma)-  be  heard  a  systolic  murmur,  or  more 
commonly  a  venous  hum. 

4.  Xcrvous  symptoDis  are  common  to  almost  all  cases,  but 
there  is  considerable  varict)^  in  the  extent  to  which  they  are 
developed. 

Emotional  and  mental  disturbances  are  common.  There 
may  be  hysteria,  neurasthenia,  irritabilit}-  of  temper,  and 
mental  depression  often  passing  into  melancholia.  There 
may  be  temporary  mania.  There  is  a  tendency  to  general 
neuralgic  pains.  Symptoms  of  general  paresis  have  been 
observed  in  a  few  instances. 

Muscular  tremors  comprise  one  of  the  most  constant 
symptoms  of  the  disease.  The  tremor  is  usually  fine, 
generally  first  involving  the  hands,  and  is  more  marked  on 
motion.  It  may  become  general,  and  may  even  interfere 
with  the  walking  power.  In  rare  cases  the  tremor  may  be 
limited  to  one  member. 

There  is  usually  insomnia.  There  may  be  attacks  of 
precordial  pain  resembling  pseudo-angina.  The  skin  is 
persistently  moist  with  perspiration,  and  the  electrical  resist- 
ance of  the  body  is  diminished. 

Derangements  of  the  digestion  are  common.  There  may 
be  intermitting  attacks  of  diarrhoea  and  flatulency,  with 
severe  and  distressing  vomiting  resembling  the  gastric  or 
gastro-intestinal  crises  of  locomotor  ataxia.  There  may  be 
pigmentation  of  the  skin  as  in  Addison's  disease,  or  patches 
of  leucoderma.  The  hair  may  become  white  or  may  fall 
out.  Urticaria  and  angio-neurotic  oedema  of  the  skin  are 
common.  There  may  be  slight  irregular  fever  without 
known  cause. 

Alternating  flushings  and  pallor  of  the  face  with  hot  and 
cold  flashes  are  common.  Menstrual  disorders  frequently 
occur,  amenorrhcea  being  the  rule,  although  menorrhagia 


EXOrUTJ/.lf.MlC   GOfTRE.  249 

may  occur.  There  may  be  paroxysmal  dyspnoea  occurring 
especially  with  the  attacks  of  palpitation. 

Prognosis. — Exophthalmic  goitre  runs  usually  a  chronic 
course  extending  over  years.  It  is  seldom  fatal  except  from 
the  dilatation  of  the  heart  that  may  be  induced.  A  certain 
number  of  patients  recover  completely  or  in  part,  but  when 
the  disease  is  well  developed  recovery  is  rare.  There  are 
some  acute  cases  following  fright  in  which  recovery  is 
rapid. 

Treatment. — The  general  nervous  and  anaemic  condition 
should  receive  efficient  treatment.  The  diet  should  be 
nutritious  and  digestible.  Moderate  exercise  in  the  open 
air  is  to  be  enforced  systematically  if  possible.  All  causes 
for  nervous  irritation  should  be  avoided,  and  iron  with 
arsenic  or  inhalations  of  oxygen  gas  should  be  given, 
together  with  general  nervines  and  tonics.  The  action  of 
the  heart  should  be  regulated.  Digitalis  and  strophanthus 
may  succeed,  but  they  are  not  reliable.  Convallaria  often 
does  good  when  digitalis  fails.  Ergot  may  be  employed 
with  benefit,  and  belladonna  given  until  dryness  of  the 
throat  is  obtained  may  be  of  service.  Brilliant  results  often 
are  obtained  by  iodide  of  potassium  in  5-  or  lo-grain  doses 
three  times  a  day  combined  with  from  10  to  15  grains  of 
sodium  bromide.  This  combination  is  especially  indicated 
where  the  heart's  action  is  rapid  and  forceful  with  subjec- 
tive feelings  of  palpitation.  Good  results  are  claimed  for  the 
use  of  sodium  glycerophosphate  in  15-  to  20-grain  doses 
three  or  four  times  a  day.  In  cases  with  marked  gastro- 
intestinal symptoms  colon  irrigations  daily  are  of  service, 
and  several  cases  of  apparently  permanent  cure  have  been 
reported  from  this  procedure  alone. 

Aconite  and  veratrum  viride  are  not  of  much  benefit. 
Rest  in  bed  with  cold  applications  (as  an  ice-bag  or  Leiter's 
coil)  over  the  heart  are  often  efficient.  In  less  severe  cases 
a  smooth  piece  of  ice  may  be  rubbed  briskly  over  the  heart 
for  fifteen  minutes  two  or  three  times  a  day. 

The  use  of  galvanism  has  been  recommended  highly, 
and  it  should  always  be  tried  as  a  routine  measure.  The 
cathode  should  be  placed  at  the  back  of  the  neck  or  at  the 


250        MA.VL'AI.    OF   THE   PKACTICE    OF  MFDICIXE. 

angle  of  the  jaw,  while  the  anode  is  placed  over  the  course 
of  the  sympathetic  in  the  neck  or  over  the  heart.  An 
application  for  fifteen  minutes  every  second  day  is  suf- 
ficient. 

Feeding  with  raw  thyroid  glands  of  the  sheep  and 
hypodermic  injections  of  thyroid  extract  have  been  em- 
ployed, but  with  unfavorable  results.  The  results  obtained 
with  desiccated  thymus  gland  and  with  suprarenal  extract 
have  not  been  altogether  favorable.  In  severe  cases  thy- 
roidectomy may  be  resorted  to  with  a  fair  percentage  of 
cures  and  improvements  ;  but  the  operation  is  in  itself  a 
considerable  source  of  danger.  Ligation  of  the  thyroid 
arteries  has  been  recommended. 


5.  CONGENITAL  MALFORMATIONS. 

Congenital  malformations  may  be  due  to  arrested  or 
abnormal  development  or  to  endocarditis  during  fetal  life. 
The  following  classification  is  the  one  generally  adopted : 

Patency  of  the  Foramen  Ovale. — If  the  patency  exists 
in  but  small  degree,  it  is  not  of  serious  importance  unless 
accompanied  by  other  anomalies.  The  greater  degrees 
of  patency  are  not  incompatible  with  fairly  prolonged 
life.  In  these  cases  the  diagnosis  can  be  suspected  by 
marked  cyanosis,  either  without  heart-murmurs  (fairly 
diagnostic)  or  by  systolic  and  presystolic  murmurs  heard 
over  the  mid-sternum  at  the  level  of  the  third  and  fourth 
ribs. 

Defects  of  the  Septa. — Minor  defects  of  the  ventricular 
systole  are  not  rare  and  are  not  of  much  importance. 
Major  defects  rarely  occur  alone,  but  usually  are  associated 
with  stenosis  of  the  pulmonary  valve,  forming  a  most 
serious  lesion.  The  defect  results  in  the  propulsion  of 
blood  from  the  stronger  left  ventricle  into  the  right  heart 
during  systole,  leading  to  embarrassed  respirations  and 
venous  congestions.  The  physical  sign  is  a  loud  .systolic 
murmur  heard  over  the  whole  precordium  and  between  the 
shoulders,  and   not  transmitted.     Both   auricular  and  ven- 


CONG  EN/  TA  L    MAL  FORMA  7  VONS.  2  5  I 

tricular  septa  may  be  defective,  producing  the  cor  diiocii- 
lare,  or  the  reptilian  heart. 

Stenosis  or  Incompetence  of  the  Tricuspid  and  Mitral 
Valves. — These  defects  are  rare.  For  physical  signs  see 
Chronic  Endocarditis,  pp.  204—227. 

Stenosis  and  Atresia  of  the  Pulmonary  Orifice  or  of 
the  Conus  Arteriosus. — These  affections  comprise  the 
most  important  group  of  cases,  being,  moreover,  relatively 
common.  Pulmonary  stenosis  alone  is  not  inconsistent 
with  life  for  some  years.  For  the  physical  signs  see 
Pulmonary  Stenosis,  p.  222.  The  lesion,  however,  is  usually 
associated  with  defects  of  the  ventricular  septum,  and  the 
prognosis  is  thereby  rendered  far  more  serious. 

Persistence  of  the  Ductus  Arteriosus. — This  channel 
should  normally  be  closed  on  the  fourteenth  day.  If 
patent,  there  result  rapid  hypertrophy  and  dilatation  of  the 
right  ventricle,  dilatation  of  the  pulmonary  artery,  dyspnoea, 
cyanosis,  and  congestion  of  the  lungs,  with  general  venous 
congestions.  The  physical  signs  are  a  long-continued 
systolic  murmur  over  the  pulmonary  area,  a  systolic  thrill, 
and  a  protrusion  of  the  upper  part  of  the  sternum. 

Stenosis  of  the  Aortic  Orifice. — Stenosis  of  the  aorta  is 
rare.  It  is  a  serious  lesion,  incompatible  with  life  for  more 
than  a  few  weeks.  Stenosis  of  the  conus  arteriosus  is  not 
inconsistent  with  a  fairly  prolonged  life.  The  circulation  is 
carried  on  by  anastomoses  between  branches  of  the  sub- 
clavian with  those  of  the  epigastric  and  intercostal  arteries. 
The  arteries  of  the  upper  extremities  are  regularly  larger 
and  fuller  than  those  of  the  lower. 

Transposition  of  Arterial  Trunks. — This  condition  is 
necessarily  fatal  /;/  utcro,  unless  compensated  by  other 
anomalies,  such  as  open  foramen  ovale  or  communication 
between  the  pulmonary  vein  and  the  right  side  of  the  heart. 

Numerical  Anomalies  of  the  Valve-segments. — Super- 
numerary valves  are  of  no  significance.  Deficiency  of 
valve-segments  is  usually  associated  with  other  and  more 
serious  anomalies. 

Ectopia  cardis  may  occur  with  congenital  fissure  of  the 
sternum  and  abdomen.     Displacement  of  the  heart  into  the 


25::        MAXrAL    OF  THE   PKACTICE    OF  MEDICIXE. 

neck  or  the  abdomen  may  occur.  There  ma\'  be  acardia, 
double  heart,  bifid  apex,  or  absence  of  the  pericardium. 

Symptoms. — Radical  defects  are  inconsistent  with  life, 
so  that  the  child  dies  ///  utcro  or  shortly  after  birth.  In 
those  who  live  cyanosis  is  so  marked  a  feature  that  the 
name  "  morbus  creruleus "  has  been  given  to  the  disease, 
and  the  term  "  blue  babies "  has  been  applied  to  these 
children.  The  c\-anosis,  which  may  be  constant  or  may  be 
induced  onh'  by  exertion  or  by  crying,  varies  from  a  lead 
color  to  a  purplish  hue.  The  child  shows  retarded  mental 
and  physical  development.  The  nails  are  clubbed.  The 
external  temperature  is  low,  and  there  is  a  great  suscepti- 
bility to  cold.  Pulmonary  affections  are  common,  dyspnoea 
and  cough  are  frequently  observed,  and  the  child  is  apt  to 
succumb  to  an  attack  of  bronchitis  or  of  pulmonary  con- 
gestion, or  to  any  of  the  ordinary  diseases  of  childhood. 

Treatment  consists  in  guarding  the  child  from  cold  and 
in  checking  promptly  intercurrent  diseases.  The  treatment 
for  the'heart  itself  is  the  same  as  that  for  valvular  disease 
of  adults. 


6.  DISEASES  OF  THE  ARTERIES. 

ARTERIO-SCLEROSIS. 

Etiology  and  Synonyms. — Arterio-sclerosis  occurs  as  a 
disease  of  advanced  age,  usually  in  those  over  forty.  It  is 
one  of  the  conditions  of  senility.  Predisposition  to  arterial 
degeneration  runs  in  some  families  and  may  be  inherited. 
Among  the  exciting  causes  are  chronic  alcoholism,  lead- 
poisoning,  gout,  syphilis,  diabetes,  and  over-eating,  espe- 
cially with  sedentary  habits  of  life.  There  may  be  an  ante- 
cedent history  of  uric-acid  diathesis.  The  disease  is  common 
with  chronic  articular  rheumatism,  and  may  precede,  follow, 
or  develop  simultaneously  with  Bright's  disease,  especially 
with  the  granular  kidney.  It  may  follow  severe  over-work 
of  the  muscles.    Synonyms:  Chronic  endarteritis;  Atheroma. 

Patholog-y. — The  aorta  is  almost  alwa\'s  affected  ;  next 
in  frequency  come  the  larger  arteries.  The  disease  may  be 
uniformly  distributed,  or  it  may  involve  some  arteries  and 


A  R  TE  R  ro-  SCL  E  R  OS/S.  253 

not  others  ;  it  may  be  either  circumscribed  or  diffuse.  The 
intima  is  much  thickened  by  an  increase  of  connective 
tissue  and  by  the  deposit  of  round  cells.  These  cells  may 
undergo  fatty  degeneration,  imparting  a  yellow  color  in 
patches  to  the  interior  of  the  artery.  In  the  deeper  tissues 
the  cells  may  break  down  to  form  a  mixture  of  fat,  detritus, 
and  cholesterin-crystals  from  which  the  name  "  atheroma," 
or  "  pulp,"  is  derived ;  or,  if  near  the  surface,  an  atheroma- 
tous ulcer  is  formed.  Atheromatous  patches  and  ulcers  and 
the  narrowed  lumen  allow  of  the  formation  of  thrombi.  In 
other  cases  the  intima  becomes  markedly  sclerotic  and  of 
bony  hardness  from  the  deposit  in  it  of  salts  of  lime.  The 
media  and  the  adventitia  may  show  similar  changes,  even 
to  fatty  degeneration  and  calcification,  or  the  media  may 
become  atrophied. 

Seco7idary  lesions  are  found  chiefly  in  the  heart.  The 
arterial  lesion  produces  loss  of  elasticity,  and  consequently 
increases  peripheral  resistance  to  the  work  of  the  heart. 
The  thickening  of  the  intima  may,  moreover,  cause  such  a 
narrowing  of  the  lumen  of  the  vessels  that  an  added  resist- 
ance results ;  in  consequence,  the  left  ventricle  becomes 
hypertrophied  in  all  cases  in  which  the  nutrition  of  the 
patient  is  good,  and  compensation  is  effected.  Should 
general  nutrition  fail,  dilatation  will  ensue. 

The  hypertrophied  heart,  pumping  blood  into  the  vessels 
whose  outflow  is  impeded,  raises  arterial  tension  generally 
and  causes  an  accentuation  of  the  second  aortic  sound. 

The  changes  in  the  aorta  may  so  weaken  its  wall  as  to 
allow  the  formation  of  an  aneurysm.  For  the  same  reason 
miliary  aneurysms  may  be  formed  in  the  cerebral  arteries 
and  may  result  in   rupture  and  cerebral  hemorrhage. 

Dry  gangrene  of  the  extremities  may  result  from  dimin- 
ished supply  of  blood  from  the  narrowing  of  the  arterial 
lumen  by  connective  tissue  or  thrombi. 

Associated  Lesions. — Contracted  kidney  occurs  in  the 
great  majority  of  cases.  It  is  often  difficult  to  decide  in  a 
given  case  whether  the  arterial  or  the  renal  disease  has 
been  primary. 

Emphysema  with  chronic  bronchitis  is  present  in  a  large 


254        .VAXr.-lL    OF   THE   PKACVVCE    OF  MEDICINE. 

number  of  cases,  and  the  patient  is  liable  to  have  cirrhosis 
of  the  liver,  as  alcoholism  is  a  common  fictor  in  cirrhosis 
and  in  arterial  sclerosis.  Atheroma  of  the  aortic  valves  is 
a  frequent  complication. 

The  symptoms  are  exceedingly  diverse,  depending  upon 
which  arteries  are  most  affected  and  upon  the  secondary 
and  associated  lesions.  Arterial  sclerosis  with  compensa- 
tory hypertrophy  is  not  inconsistent  with  general  good 
health.  When  compensation  fails  the  general  symptoms  of 
dilatation  and  heart-inefficiency  occur. 

Sclerosis  of  the  coronary  arteries  may  produce  throm- 
bosis with  sudden  death,  fibroid  degeneration,  aneurysm  or 
rupture  of  the  heart,  and  angina  pectoris. 

Cerebral  symptoms  are  those  of  cerebral  endarteritis 
(which  see),  comprising  acute  and  chronic  degeneration, 
spasm  of  cerebral  vessels  with  transient  or  permanent 
paralyses,  and  cerebral  hemorrhages. 

Renal  symptoms  may  be  absent,  or  the  urine  may  be 
increased  in  quantity  and  of  low  specific  gravity,  with  but 
occasionally  hyaline  casts  and  a  trace  of  albumin.  In 
other  cases  the  renal  symptoms  are  distinctly  uraemic  and 
may  terminate  the  life  of  the  patient. 

The  course  of  the  disease  may  be  complicated  by  aneur- 
ysm, by  gangrene,  or  by  an  associated  emphysema. 

Physical  Signs. — The  combination  of  increased  arterial 
tension,  hypertrophy  of  the  left  ventricle,  accentuation  of 
the  second  aortic  sound,  and  an  appreciable  thickening  of 
the  arteries  affords  conclusive  proof  of  the  existence  of 
arterio-sclerosis.  A  high-tension  pulse  may  exist  with 
very  little  sclerosis,  but  sclerosis  and  high  tension  usually 
go  together  except  when  the  left  ventricle  fails.  The  pulse- 
wave  is  slow  in  its  ascent,  is  felt  for  an  appreciably  long 
period,  subsides  slowly,  and  between  the  beats  the  pulse 
remains  firm  and  full.  The  wave-fluctuations  are  compara- 
tively small.  It  is  difficult,  even  impossible  in  some  cases, 
to  obliterate  the  pulse  by  firm  pressure  on  the  artery.  The 
sphygmographic  tracing  (Fig.  19)  shows  a  short  slanting  up- 
stroke, a  flat  or  rounded  summit,  and  a  gradual  descent  in 
which  the  dicrotic  wave  is  slighly  marked  or  absent. 


ARTKRITIS. 


Platk  1 6. 


y^. 


•,  r•.^*^•.•^*»-•5!J;,■ 


%     >ri 


Small  artery:  thickening  of  all  the  coats  (Delafield). 


ARTERITIS. 


I' LATE  17. 


^^•' 


■*^  "V 


"V 


Small 


artery:  obliterating  endarteritis  (Delafi, 


eld). 


ARTERITIS. 


Platk  1 8. 


^z 


^i>-- 


.^X 


f 


''  I, 


■■% 


^^ 


% 

t 
I 

'') 

4 


'( 


Syphilitfc  endarteritis  fFin?p.-l  ■  !    \, 

If  ingei)  .  b  shows  thickened  int 


SYPif/LfTic  AirncNiTis.  255 

The  prognosis,  so  far  as  life  is  concerned,  is  not  unfavor- 
able. The  danger  of  renal  or  cardiac  disease  or  of  cerebral 
complications  is  always  present.  The  chief  question  is 
whether  compensatory  hypertrophy  of  the  left  ventricle  can 
be  maintained.     Sudden  death  may  occur. 

Treatment. — Much  can  be  done  to  limit  the  extension  of 
the  disease  by  a  quiet  mode  of  life,  plain,  non-.stimulating 
diet,  and  a  correction  of  those  conditions  known  to  pro- 
duce the  disease.     The  state  of  the  bowels  and  of  the  urine 


Fig.  19. — Sphygmogram  showing  high-tension  pulse. 

should  be  regarded,  and  the  skin  should  be  kept  active  by 
daily  baths.  Alcohol  is  to  be  prohibited.  High  blood- 
tension  should  be  reduced  by  appropriate  drugs.  Of  these, 
nitroglycerin  is  the  most  serviceable,  given  in  doses  of  gr. 
y-^  every  three  or  four  hours,  or  at  longer  intervals  if  not 
well  borne.  Iodide  of  potassium  in  gr.  x  doses  t.  i.  d.  is  of 
service,  especially  in  syphilitic  patients.  It  is  advantage- 
ously combined  with  choral  in  gr.  v-x  doses.  Sudden  and 
severe  muscular  efforts  should  be  avoided,  especially  if  the 
aorta  be  extensively  involved.  When  the  heart  begins  to 
dilate,  stimulants  will  be  required.  Digitalis  should  not  be 
given,  however,  unless  its  effect  in  raising  arterial  tension 
be  balanced  by  its  combination  with  nitroglycerin.  Should 
acute  dilatation  occur,  with  lividity  and  dyspnoea,  venesec- 
tion may  be  resorted  to. 

SYPHILITIC    ARTERITIS. 

Besides  sj'philis  being  a  causative  factor  in  arterio-sclerosis 
and  aneurysm,  two  specific  forms  of  arteritis  are  described  : 

I.  Obliteraiing  endarteritis  with  proliferation  of  new  tissue 
within  the  intima,  obstructing  the  lumen.  There  is  also 
a  small-celled  infiltration  of  the  middle  and  external  coats. 
This  form  of  infiltration  is  not  absolutely  characteristic  of 


256        MA.yr.lL    OF  THE   PRACTICE    OF  MEDICINE. 

syphilis,  but  should  be  so  regarded  should  other  syphilitic 
changes   be  found. 

2.  Gitvimatous  Pcri-artcritis. — Guninia  develop  within 
the  adventitia,  forming  ovoid  swellings  along  the  course 
of  the  artery.  There  is  usually  an  associated  obliterating 
endarteritis.  This  process  is  distinctive  of  syphilis,  and 
occurs  especially  in  the  coronary  and  cerebral  arteries. 

ANEURYSM. 
The  following  forms  of  aneurysm  occur: 

1.  True  aneurysm,  in  which  the  sac  is  formed  by  the 
arterial  coats.  The  aneurysm  may  be  cylindrical,  fusiform, 
or  sacculated. 

2.  False  or  dissecting  aneurysm,  in  which,  from  laceration 
of  the  intima,  blood  makes  its  way  between  the  layers  and 
may  rupture  through  the  outer  coats. 

3.  Arterio-ve/ious  aneurysm,  where  a  communication  ex- 
ists between  an  artery  and  a  vein.  If  there  be  an  interven- 
ing sac,  the  term  varicose  aiie?irysin  is  applied ;  if  the  com- 
munication be  direct,  the  condition  is  termed  aneurysmal 
varix. 

Etiology. — There  is  always  some  weakness  of  the  arterial 
wall,  so  that  it  becomes  dilated  from  the  blood-pressure. 
There  is  almost  regularly  arterial  sclerosis,  and  the  con- 
ditions which  produce  this  sclerosis  are  therefore  causative 
factors  of  aneurysm.  Bacterial  infection  of  the  aortic  wall, 
producing  aneurysm,  has  been  observed  with  malignant 
endocarditis. 

Embolism  may  lead  to  aneurysm  by  causing  local  degen- 
eration or  injury  of  the  vessel-wall. 

The  determining  cause  of  aneurysm  is  high  arterial  pres- 
sure from  the  arterial  sclerosis  or  from  severe  muscular 
efforts.  Aneurysm  is  more  common  in  men  than  in  women, 
and  is  more  frequent  among  the  working  classes,  as  long- 
shoremen, in  whom  alcoholism,  syphilis,  and  over-work  are 
important  factors.  It  is  rare  before  thirty  and  after  fifty 
years  of  age,  because  arterial  sclerosis  does  not  appear  be- 
fore the  earlier  limit,  and  because  muscular  strain  is  not  so 
common  after  the  latter  age. 


ANEURYSM.  257 

Pathology. — The  cavity  of  the  aneurysm  usually  contains 
clots  of  blood,  frequently  laminated  and  partly  organized. 
There  may  be  calcareous  degeneration  of  the  clot.  The 
vessels  leading  from  the  artery  at  the  site  of  the  aneurysm 
may  be  occluded ;  portions  of  the  clot  may  become  de- 
tached and  carried  into  the  circulation  as  emboli.  Organ- 
isation of  the  clot  is  conservative  in  its  nature  and  is  more 
common  in  sacculated  aneurysm. 

The  aneurysm-wall  is  never  composed  of  normal  vessel- 
wall.  The  intima  shows  marked  changes  of  arterial  sclero- 
sis. The  media  is  changed,  and  is  often  in  a  condition  of 
fatty  degeneration.  The  adventitia  is  thickened  by  inflam- 
matory processes,  thus  reinforcing  the  weakened  arterial 
wall.  The  intima  and  the  media  may  atrophy  so  that  the 
wall  consists  of  the  adventitia  alone. 

Aneurysms  vary  in  size  from  microscopic  miliary  aneur- 
ysms to  those  the  size  of  a  child's  head  or  larger. 

Aneurysms  may  rupture,  may  compress  neighboring 
organs,  and  may  cause  pressure-erosion. 

The  situation  of  aneurysms  varies.  In  860  cases  ana- 
lyzed by  Sibson,  the  situation  of  the  aneurysm  was  as 
follows :  The  ascending  portion  of  the  arch,  141  ;  the 
transverse  portion  of  the  arch,  120;  the  ascending  and 
transverse  portions  together,  112;  the  sinuses  of  Valsalva, 
87 ;  the  descending  portions  of  the  arch,  72  ;  the  transverse 
and  descending  portions  together,  20 ;  the  whole  arch,  28 ; 
the  thoracic  aorta,  71  ;  the  abdominal  aorta  at  the  coeliac 
axis,   131  ;  the  lower  part  of  the  abdominal  aorta,  26. 

Symptoms. — An  aneurysm,  being  a  pulsating  tumor  in 
the  course  of  the  arterial  circulation,  growing  in  the  stiff- 
walled  thorax,  and  having  a  tendency  to  rupture,  naturally 
produces  four  groups  of  symptoms  :  (i)  The  presence  of  a 
growing  pulsating  tumor ;  (2)  its  pressure  on  surrounding 
parts;  (3)  its  effect  upon  the  circulation  of  the  blood; 
(4)  the  symptoms  due  to  erosion  and  rupture. 

Symptoms  of  Aneurysm  of  the  Thoracic  Aorta. — 
Pressure-symptoms  are  usually  marked,  and  afford  data  for 
the  localization  of  the  aneurysm. 

I.  Pressure  on  the  Vena  Cava  or  its  Brajiches. — There 
17 


258        .)/./.\YWZ    OF  THE   PRACTICE    OF  MEDJCIXE. 

may  be  congestion  and  oedema  of  the  arm  and  the  face  on 
one  side,  more  rarely  on  both  ;  or  in  old-standing  cases 
there  may  be  a  brawny  swelling  of  the  base  of  the  neck, 
termed  by  the  French  "  the  collar  of  flesh."  Large  aneur- 
ysms of  the  ascending  aorta  sacculated  downward  may  press 
on  the  inferior  vena  cava,  causing  oedema  of  the  feet  and 
ascites.  There  may  be  erosion  from  pressure  and  rupture 
into  the  superior  vena  cava  with  aneurysms  of  the  ascend- 
ing arch.  Congestion  of  the  chest-wall  occurs  from  pres- 
sure on  the  azygos  vein. 

2.  Prcssitrc  on  the  Trachea  and  the  Bronchi. — Moderate 
pressure  causes  symptoms  of  inflammation  and  cough  with 
expectoration  which  may  contain  blood.  More  marked 
pressure  on  the  trachea  causes  inspiratory  dyspncea,  either 
steady  or  paroxysmal,  or  orthopncea.  There  are  developed 
s}'mptoms  of  gradual  asphyxia.  In  some  cases  sudden 
fatal  asphyxia  may  occur  either  from  pressure-erosion  of  a 
tracheal  ring,  allowing  the  trachea  to  collapse  suddenly 
like  a  membranous  tube,  or  from  the  lodgement  of  a  plug 
of  mucus  at  the  pressure-point,  causing  total  obstruction. 
Tracheal  compression  is  usually  seen  with  aneurysms  of 
the  transverse  arch.  Compression  of  a  bronchus  causes 
localized  bronchial  catarrh  with  sibilant  and  sonorous 
rales,  dyspnoea,  and  diminished  breathing  over  that  part  of 
the  lung.  There  may  be  bronchiectasis  and  suppuration 
of  the  lung.  The  left  bronchus  is  the  one  more  frequently 
compressed.     With  large  aneurysms  the  lung  may  be  par- 

.tially  compressed. 

Rupture  may  occur  into  the  lung,  the  trachea,  or  the 
bronchi.  A  large  hemorrhage  will  cause  death  by  anemia, 
or,  filling  the  bronchi,  cause  asphyxia  or  septic  broncho- 
pneumonia. Small  repeated  hemorrhages  may  occur  from 
moderate  leakage.  Aneurysms  of  the  descending  arch 
often  rupture  into  a  pleural  sac. 

3.  Pressure  on  the  cesophagns  occurs  with  aneurysms  of 
the  descending  aorta,  more  rarely  with  those  of  the  trans- 
verse arch.  Dysphagia  may  be  either  steady  or  parox- 
ysmal, and  may  lead  to  great  emaciation.  The  case  may 
resemble    one    of  oesophageal    stricture,    and    care    should 


ANEURYSM.  259 

always  be  taken  in  such  cases  to  exclude  thoracic  aneur- 
ysm before  passing  an  oesophageal  bougie,  as  otherwise 
instrumental  rupture  of  the  aneurysmal  sac  may  result. 
Rupture  into  the  oesophagus  may  occur  and  may  be  the 
first  symptom   of  an   unsuspected  aneurysm. 

4.  Pressure  or  Traction  on  the  Recurrent  Laryngeal 
Nerve. — The  left  side  is  more  commonly  affected.  There 
may  result  spasm  or  paralysis  of  one  or  of  both  vocal 
cords.  There  is  dyspnoea  which  is  steady  or  paroxysmal ; 
a  brassy  or  clanging  cough  quite  distinctive;  husky  or  whis- 
pering voice  or  aphonia.  Spasmodic  dyspnoea  of  laryngeal 
origin  is  differentiated  from  obstructive  dyspnoea  of  tracheal 
pressure  by  being  relieved  by  inhalations  of  chloroform. 

5.  Pressure  on  the  Sympathetic  Nerve. — In  the  early 
stages  the  pupil  on  the  affected  side  is  dilated  and  the  skin 
is  paler  than  normal ;  later  occur  contraction  of  the  pupil 
and  flushing  and  sweating  of  the  skin. 

6.  Pressure  on  the  brachial  plexus  causes  neuralgic  pains, 
twitchings,  and  later  areas  of  anaesthesia. 

7.  Pressure  on  the  Bones. — Pressure  on  the  vertebrae 
causes  the  erosion  of  their  bodies  with  a  steady  boring  pain 
in  the  back  that  is  distinctive  of  aneurysms  of  the  descend- 
ing aorta.  Complete  erosion  will  expose  the  spinal  cord  to 
pressure  with  the  symptoms  of  a  transverse  myelitis. 

8.  Pressure  on  the  intercostal  nerves  causes  neuralgic  pain. 
Pressure  on  the  sternum  and  the  ribs  is  common  with  aneur- 
ysms of  the  ascending  arch.  Boring  pain  is  experienced, 
and  there  is  apparent  a  large  pulsating  tumor  covered  finally 
only  by  red  shiny  skin  resembling  that  of  a  pointing  ab- 
scess.    External  rupture  is  the  inevitable   result. 

9.  Aneurysms  at  the  root  of  the  aorta  frequently  cause 
angina  pains. 

Physical  Signs. — Inspection  in  many  instances  is  negative. 
There  may  be  bulging  of  the  chest-wall,  best  appreciated 
with  oblique  light.  This  bulging  occurs  usually  above  the 
third  rib,  to  the  right  of  the  sternum.  Aneurysms  of  the 
ascending  aorta  are  found  projecting  in  the  left  scapular 
region.  An  external  tumor  may  be  formed  by  the  sac 
approaching  the  surface,  invading  the  intermediate  struct- 


26o        MAXC.tL    OJ-    THE   J'RACTICE    01-    MEJ>JCJA'E. 

urcs.  The  heart's  apex  is  often  displaced  downward  and 
to  the  left. 

Palpation  reveals  an  expansile  pulsation  of  the  tumor. 
There  may  be  a  heaving  impulse  without  the  appearance  of 
an  external  tumor.  There  ma\'  be  a  systolic  thrill,  and  in 
some  cases  a  diastolic  shock  which  is  highly  distinctive. 
Fluctuation  ma\-  be  detected  when  the  sac  has  perforated 
the  chest-v/all.  Care  should  be  taken,  however,  in  manipu- 
lation to  avoid  rupture  of  the  sac.  There  may  be  pulsation 
in  the  sternal  notch  in  case  of  aneurysm  of  the  transverse 
arch. 

Percussion  reveals  dulness  or  flatness  whenever  the  aneur- 
ysm is  large  enough  to  approach  the  chest-wall.  Small, 
deeply-seated  aneurysms  do  not,  therefore,  yield  dulness. 
Dulness  on  the  right  side  of  the  manubrium  indicates  aneur- 
ysm of  the  ascending  arch  ;  dulness  in  the  middle  line  ex- 
tending to  the  left  points  to  aneurysm  of  the  transverse  arch ; 
\vhile  dulness  to  the  left  of  the  spinal  column  occurs  with 
aneurysm  of  the  descending  aorta.  There  may  be  tender- 
ness on  percussion,  and  a  sense  of  abnormal  resistance. 

Auscultation  may  yield  negative  results  even  with  large 
aneurysms.  There  may  be  a  continuous  hum  louder  at  each 
systole,  or  a  systolic  or  double  murmur.  The  aortic  second 
sound  is  usually  accentuated,  or  it  may  be  replaced  b}' 
the  murmur  of  an  associated  regurgitation  at  the  aortic 
valve.  There  may  be  a  systolic  murmur  heard  over  the 
trachea,  due  to  the  expulsion  of  air  at  each  pulsation  of 
an  overlying  aneuiysm. 

The  pulse  in  the  arteries  beyond  the  aneurysm  is  fre- 
quently altered,  becoming  slowed  and  the  wave  being 
partially  effaced. 

Aneuiysms  of  the  ascending  arch  alone,  delay  all  pulses 
equally.  Large  aneurysms  of  the  descending  aorta  may  totally 
efface  the  pulse-wave  in  the  abdominal  aorta  and  femorals. 
When  the  aorta  at  the  origin  of  the  innominate  artery  is 
involved,  the  right  radial  pulse  is  more  retarded  and  effaced 
than  the  left.  When  the  trans\-erse  arch  is  involved  beyond 
the  innominate,  it  is  the  left  pulse  that  is  the  more  affected. 

Tracheal  tugging  is  a  sign  of  much  value  in   detecting 


ANEURYSM. 


261 


Fig.  20. — Aneurysm  of  the  ascending 
aorta,  showing  shape  of  the  outline  and  the 
position  of  the  customary  double  murmurs. 


deep  aneury.sms  pre.ssing  backward  upon  the  trachea  or  the 
left  bronchus.  The  patient  should  sit  with  the  chin  de- 
pressed, so  as  to  relax  the  tissues  of  the  neck.  The  exam- 
iner, standing  behind  the  patient,  raises  the  cricoid  cartilage 
on  the  tips  of  the  index 
fingers.  If  an  aneurysm  be 
present  in  the  situation  above 
noted,  a  characteristic  down- 
ward tugging  will  occur  with 
each  pulsation  This  tugging 
is  a  sign  of  great  value,  al- 
though not  absolutely  path- 
ognomonic. The  heart  may 
be  displaced  downward  and 
to  the  left.  It  is  not  usually 
enlarged  unless  from  some 
coexisting  lesion. 

Diagnosis. — Throbbing  of 
the  aorta  in  aortic  insuffi- 
ciency, and  displacement  of 
the  aorta  forward  with  spinal  curvature,  may  simulate 
aneurysm,  but  pressure-symptoms,  pain,  and  retardation 
of  the  pulse  are  absent.  Sacculated  empyema  receiving 
impulses  from  the  heart  may  cause  a  pulsating  tumor,  but 
the  pulsation  is  not  expansile,  there  are  no  circulatory 
symptoms,  and  septic  symptoms  occur. 

Pulsating  sarcoma  and  other  growths  of  the  mediastinum 
often  present  great  difficulties  in  diagnosis.  The  pulsations 
in  these  growths  are  not  expansile,  as  in  aneur3^sm,  have  less 
force  and  power,  and  have  no  diastolic  shock.  In  some 
cases  a  differential  diagnosis  between  a  pulsating  tumor 
and  an  aneurysm  is  impossible. 

The  prognosis  is  always  grave.  Recovery  may  occur, 
but  it  is  not  to  be  expected.  The  aneurysm  may  rupture  at 
any  time,  and  the  rupture  may  even  be  the  first  symptom. 
Dissecting  aneurysms  just  above  the  sinuses  of  Valsalva 
rupture  usually  into  the  pericardium,  causing  sudden  death. 
Sudden  heart  failure  is  common  with  aneurysm  without 
rupture,   and  death  may  result  from  obstructive  dyspnoea. 


26: 


M.ixr.u.  oj-  rnii  pk.ict/ck  (>/■  mkvici.xj:. 


myelitis,  dyspha;^ia,  and  exhaustion,  or  from  associated 
endocarditis  of  the  aortic  vaKes.  Tlic  course  of  the  disease 
is  usually  about  two  years,  although  life  may  be  prolonged 
in  some  cases  for  five  or  ten  years. 

The  treatment  of  aneurysm  of  the  thoracic  aorta  consists 
in  the  attempt  to  secure  coagulation  within  the  sac.  Rest 
is  an  essential  feature  of  the  treatment,  and  should  be  as 
nearly  absolute  as  possible.  Mental  excitement  of  all  kinds 
should  be  avoided.  Tufnell's  treatment  consists  in  the 
enforcement  of  rest  and  a  restricted  diet.  He  allows  for 
breakfast  2  ounces  of  bread  and  butter  with  2  ounces 
of  milk;    for  dinner,  2  or  3  ounces  of  bread   and  2  or  3 


Fig.  21. — Sphygmograms  of  the  radial  pulse  on  the  right  (a)  and  the  left  side  (i^),  from  a 
case  of  aneurysm  of   the  transverse  part  of  the  arch  of  the  aorta, 

ounces  of  meat,  with  from  2  to  4  ounces  of  milk  or  claret ; 
for  supper,  2  ounces  of  bread  and  2  ounces  of  milk.  This 
plan  succeeds  best  in  small  sacculated  aneurysms.  Few 
patients,  however,  can  stand  such  a  radical  reduction 
of  food,  so  this  treatment  cannot  be  enforced  rigor- 
ously. A  more  liberal  supply  may  be  given,  but  fluids 
should  be  restricted  as  much  as  possible.  Systematic  bleed- 
ing may  prove  of  service  in  the  earlier  stages  in  robust  sub- 
jects: 8  or  10  ounces  of  blood  may  be  abstracted  every 
ten  days  or  two  weeks,  provided  that  excessive  ansemia  is 
not  produced. 

Of  medicines,  iodide  of  potassium  is  most  commonly  em- 
ployed, the  aim   being  to   tranquillize  the   circulation   and 


ANEURYSM   OF   "J'lIE   ABDOMINAr.    AORTA.  263 

reduce  blood-tension  without  increasing  the  frequency  of  the 
pulse.  To  find  the  proper  dose  the  patient  should  be  put  to 
bed  for  several  days,  to  find  the  rapidity  of  the  pulse  at  rest. 
Then  the  iodide  is  to  be  given  in  5-grain  doses,  well  diluted, 
three  times  a  day,  and  gradually  increased  as  long  as  the 
pulse  is  not  made  more  frequent.  Rarely  more  than  10 
or  15  grains  three  times  a  day  are  necessary.  One  marked 
effect  of  the  iodide  is  the  reduction  of  pain. 

Aconite  may  be  used  for  temporary  over-action  of  the 
heart,  but  its  administration  for  any  length  of  time  is  not 
recommended. 

Various  forms  of  local  treatment  have  been  recommended, 
but  with  indifferent  success.  The  insertion  of  horse-hair, 
catgut,  wire,  and  the  injection  of  styptics  into  the  sac  have 
been  tried.  Loreta's  method  has  been  followed  in  some 
cases  by  good  results.  This  treatment  consists  in  filling  the 
sac  with  fine  silver  wire  pushed  through  a  hypodermic 
needle,  combined  with   electrolysis. 

Special  symptoms  are  to  be  treated  as  they  arise.  Dysp- 
noea and  congestion  may  be  relieved  by  timely  venesection. 
Morphine  is  to  be  employed  for  pain.  Urgent  dyspnoea 
may  seem  to  indicate  a  tracheotomy,  but  the  operation  is 
usually  useless,  as  the  obstruction  is  below  the  site  of  the 
operation  in  nearly  all  cases.  If  chloroform  inhalations  re- 
lieve the  dyspnoea,  and  if  laryngoscopic  examination  reveals 
bilateral  abductor  paralysis,  the  operation  may  be  resorted 
to.  External  rupture  is  to  be  retarded  by  painting  the  sur- 
face with  a  solution  of  gutta-percha,  by  the  use  of  ice-bags, 
or  by  a  metal  or  an  elastic  support. 

ANEURYSM    OF    THE    ABDOMINAL    AORTA. 

The  usual  situation  of  aneurysms  of  the  abdominal  aorta 
is  near  the  coeliac  axis,  which  is  frequently  involved.  The 
aneurysm  maybe  fusiform  or  sacculated,  and  may  be  multiple. 
It  may  project  backward,  eroding  the  vertebrae,  or  it  may 
project  forward,  attaining  considerable  size.  It  may  rupture 
into  the  pleura,  the  retroperitoneal  tissues,  the  peritoneum, 
or  the  intestines. 

Symptoms. — Pain  is  the  most  prominent  symptom ;   it 


264        .V.LVr.-l/.    OF   THE   PRACTICE    OF  MFDICIXE. 

may  be  sharp,  shootings,  radiating  down  the  legs,  or  it  may 
be  the  steady  boring  pain  of  bone-erosion.  Gastric  symp- 
toms are  common,  especially  gastralgia  and  vomiting.  Em- 
bolism of  the  mesenteric  artery  may  occur,  producing  severe 
colick}'  pain.  Para:sthesia  and  paraplegia  may  result  from 
pressure  on  the  cord. 

Physical  Signs. — There  may  be  a  pulsating  tumor  ap- 
parent on  inspection.  By  palpation  a  tumor  of  expansile 
pulsation  is  appreciated.  There  may  be  heard  a  systolic, 
diastolic,  or  double  murmur.  The  pulse  in  the  femorals  is 
retarded  and  may  be  obliterated.  To  avoid  mistaking  a 
throbbing  aorta  for  aneurysm,  Osier  sa\'s,  "  It  is  to  be 
remembered  that  no  pulsation,  however  forcible,  nor  the 
presence  of  a  thrill  or  a  systolic  murmur,  justifies  the 
diagnosis  of  abdominal  aneurysm  unless  there  is  a  definite 
tumor  wliicli  can  be  grasped  and  which  has  an  expansile 
pnlsationT  A  tumor  of  the  pylorus  with  an  impulse  trans- 
mitted from  the  underlying  aorta  may  be  mistaken  for 
aneur\-sm,  but  the  impulse  is  not  expansile  and  is  lost  when 
the  patient  assumes  the  knee-chest  position,  the  tumor  fall- 
ing forward  away  from  the  aorta. 

The  prognosis  of  abdominal  aneurysm  is  grave,  although 
recovery  is  not  impossible. 

The  treatment  generally  is  that  of  thoracic  aneurysm. 
Pressure  on  the  proximal  portion  of  the  aorta  may  be 
resorted  to  under  chloroform.  Pressure  should  not  be  too 
severe,  as  bad  results  have  followed  the  bruising  of  the  sac. 


m,  DISEASES  OF  THE  RESPIRATORY 
SYSTEM. 


L  DISEASES  OF  THE  LARYNX. 
SPASM  OF  THE  LARYNX. 

Two  forms  of  spasm  of  the  larynx  are  recognized : 
(i)  Laryngismus  stridulus;  (2)  Spasmodic  laryngitis. 

I.  Laryngismus  Stridulus  (Thymic  Asthma). — This 
form  occurs  in  children  under  two  and  a  half  years  of  age. 
Rickets  is  found  in  two-thirds  of  the  cases.  It  is  more 
common  in  boys,  in  delicate,  dyspeptic,  and  nervous  chil- 
dren. It  is  less  frequent  in  America  than  in  England, 
France,  or  Germany.     It  may  be  a  symptom  of  tetany. 

Etiology. — The  attack  may  be  induced  by  any  reflex 
cause  for  irritation,  such  as  dyspepsia,  poor  air,  constipa- 
tion, dentition,  or  attacks  of  crying  ;  it  is  favored  by  inflam- 
mation of  any  part  of  the  respiratory  tract. 

Patholog-y. — The  disease  consists  of  a  spasm  of  the 
adductors  of  the  larynx,  without   inflammatory  basis. 

Symptoms. — The  attacks  may  come  at  any  time,  but 
they  are  most  common  just  as  the  child  awakes.  Re.spira- 
tion  is  suddenly  arrested  ;  the  child  struggles  for  breath ; 
the  face  is  pale,  cyanotic,  or  congested  ;  the  pulse  becomes 
weak  and  flickering;  after  a  number  of  seconds  the  .spasm 
relaxes  and  air  is  inspired  with  a  loud  crowing  sound. 
During  the  attack  there  may  be  spasm  of  the  hands  and 
feet  ("  carpopedal  spasms "),  or  even  general  convulsions. 
The  attack  is  not  accompanied  by  cough,  hoarseness,  or 
fever.  The  paroxysms  may  be  as  frequent  in  severe  cases 
as  thirty  or  forty  during  the  twenty-four  hours,  and  they 
may  be  continued  at  intervals  for  months.  Slight  reflex 
causes  may  at  any  time  bring  on  the  paroxysms. 

The  prognosis  is  generally  good,  but  it  is  possible  for 
the  child  to  die  in  any  of  the  attacks.  Severe  spasms  may 
be  the  cause  of  meningeal  hemorrhage. 

265 


266     m.i\l:u.  of  the  pa'act/ce  of  medicixe. 

Treatment. — The  spasm  is  of  such  short  duration  tliat 
there  is  but  httle  time  for  treatment.  It  seems  be.st  not  to 
shake  the  child  nor  to  dash  water  in  its  face,  as  has  ,been 
recommended,  but  to  keep  the  child  quiet  until  the  attack 
is  over.  Should  the  apnoea  be  persi.stent,  a  hot  bath  (95° 
F.)  should  be  given  and  a  cold  compress  be  applied  to  the 
head.     Intubation  may  be  resorted  to  if  danger  be  imminent. 

Recurrences  of  the  paroxysms  may  be  prevented  by 
rectal  injections  of  chloral  hydrate  (gr.  ij-v)  in  milk  of 
asafetida  (oij),  to  which  from  2  to  5  grains  of  sodium  bromide 
may  be  added.  Swollen  gums  should  be  lanced  freely. 
The  bowels  should  be  regulated,  and  attention  be  paid  to 
the  proper  scientific  feeding  of  the  child.  Osier  recom- 
mends warm  baths  two  or  three  times  a  day  while  the  back 
and  the  chest  are  being  sponged  with  cool  water.  Any  cause 
for  reflex  irritation  should  be  discovered  and  properly 
treated.  The  importance  of  good  fresh  air  and  sunlight 
must  be  remembered  in  all  cases. 

2.  Spasmodic  Laryngitis  (Spasmodic  Croup). — This  is 
the  more  common  form  of  spasm  ;  it  occurs  regularly  in 
children  between  two  and  five  years  of  age,  and  equally  in 
strong  and  in  delicate  subjects. 

Symptoms. — The  attack  comes  regularly  after  the  first 
heavy  sleep,  usually  between  i  and  3  o'clock  a.  m.  The  child 
suddenly  awakes  and  sits  up  in  bed  with  evident  d}'spnoea. 
The  inspirations  are  noisy,  difficult,  and  "  croupy ;"  the 
voice  is  husky ;  there  is  a  brassy  "  croupy  "  cough.  The 
oppression  and  cyanosis  may  appear  alarming,  but  after  a 
time  (from  half  an  hour  to  an  hour)  the  attack  suddenly 
ceases  and  the  child  is  as  well  as  ever.  During  the  attack 
there  are  neither  constitutional  nor  inflammatory  symptoms, 
and  there  is  no  fever.  The  attack  may  be  repeated  on  sub- 
sequent nights,  but  in  these  cases  there  is  usually  added  a 
mild  catarrhal  laryngitis,  with  cough,  hoarseness,  and  possi- 
bly slight  fever,  during  the  day. 

The  prognosis  is  perfectly  good,  notwithstanding  the 
alarming  appearance  of  the  child. 

Treatment. — A  prompt  emetic  should  at  once  be  admin- 
istered, such  as  wine  of  ipecac  .oj,   or  mustard  and  water; 


ACUTE    CATARRHAL    LARYNGITIS.  26/ 

the  yellow  sulphate  of  mercury  (gr.  ij-v)  has  been  recom- 
mended, but  as  it  may  cause  gastro-enteritis  it  should  not 
be  used.  If  the  attack  persist,  hot  baths  and  hot  fomenta- 
tions to  the  throat  may  be  employed. 

ACUTE  CATARRHAL  LARYNGITIS. 

Etiology. — Many  cases  of  acute  catarrhal  laryngitis  are 
due  to  catching  cold  or  to  breathing  irritating  and  impure 
air,  especially  in  patients  with  catarrhal  affections  of  the 
nose  and  the  throat.  An  attack  may  be  induced  by  over- 
use of  the  voice.  Laryngitis  may  be  one  of  the  lesions  of 
"the  grippe  "  or  of  measles  ;  it  may  also  complicate  any  dis- 
ease of  the  bronchi  and  lungs  attended  with  cough  and 
expectoration.  It  may  also  occur  with  any  of  the  acute 
infectious  diseases. 

Patholog-y. — On  laryngoscopic  examination  the  mucous 
membrane  of  the  larynx  is  seen  to  be  red,  congested,  and 
swollen.  The  inflammation  may  be  generally  distributed 
or  it  may  involve  only  certain  areas.  The  vocal  cords  are 
usually  involved,  and  their  mobility  is  impaired.  There 
may  be  an  over-secretion  of  the  mucous  glands,  or  only  a 
slight  mucoid  exudation.  Superficial  ulcerations  may  re- 
sult in  severe  cases.  In  certain  cases  in  adults  there  may 
be  considerable  oedema  of  the  larynx,  which  may  consti- 
tute a  formidable  complication. 

Symptoms. — In  adults  the  course  of  the  disease  is 
somewhat  different  from  that  in  children.  Fever  may  be 
slight  or  absent,  but  malaise  to  some  extent  is  common ; 
slight  rigors  may  initiate  a  severe  attack.  The  voice  be- 
comes hoarse  or  is  reduced  to  a  whisper  ;  the  cough  is 
croupy  or  barking,  and  is  usually  paroxysmal  and  harass- 
ing. Pain  referred  to  the  larynx  may  be  quite  severe  and 
steady ;  it  is  usually  increased  by  swallowing,  talking,  or 
coughing.  In  other  cases  a  burning,  irritating  feeling  alone 
is  complained  of  Pressure  over  the  cricoid  cartilage  may 
cause  pain  or  a  paroxysm  of  coughing.  In  severer  cases 
with  oedema  of  the  glottis  dyspnoea  may  be  a  marked  symp- 
tom. The  difficulty  of  breathing  may  be  continuous  or 
paroxysmal;  it  may  lead  to  asphyxia.    This  complication  is 


268        MAXr.-lL    OF   THE   PRACTICE    OF  MEDICIXE. 

more  common  in  those  suffering  from  alcoholism  and 
Bright's  disease. 

///  C/ii/dnu. — The  peculiarit\-  of  laryng^itis  in  children  is 
that  it  is  often  complicated  b)-  spasm  of  the  larynx,  consti- 
tuting a  clinical  group  of  symptoms  to  which  the  names 
"  pseudo-croup  "  and  "  catarrhal  croup  "  have  been  given. 
This  complication  usually  occurs  in  the  winter  months  and 
in  children  under  three  years  of  age,  although  some  chil- 
dren continue  to  have  attacks  until  their  tenth  or  twelfth 
year.  The  symptoms  resemble  those  in  adults,  but  they 
are  more  marked  at  night.  The  child  is  usually  awakened 
b}'  severe  and  distressing  dyspnoea,  not,  however,  of  the 
same  explosive  violence  that  is  seen  in  pure  spasmodic 
laryngitis.  The  attack  wears  itself  out  in  an  hour  or  so, 
and  the  child  is  left  with  only  the  ordinary  .symptoms  of 
laryngitis. 

The  diagnosis  must  be  made  from  spasmodic  laryngitis 
and  membranous  croup.  In  spasmodic  laryngitis  the  at- 
tack begins  suddenly  with  explosive  violence,  and  between 
the  attacks  the  child  is  well  and  has  no  fever.  In  catarrhal 
laryngitis  the  child  has  been  ailing,  the  d}*spnoea  begins 
more  gradually,  and  between  the  attacks  of  dyspnoea  the 
child  has  a  cough,  the  voice  is  hoarse,  and  there  is  some  fever. 

In  membranous  laryngitis  the  dyspnoea  is  more  con- 
tinuous, the  general  symptoms  are  more  severe,  and  there 
are  usually  patches  of  membrane  on  the  pharynx  and  the 
tonsils.     The  cervical  glands  are  also  swollen. 

In  adults  laryngoscopic  examination  will  make  a  positive 
diagnosis  from  nervous  or  hysterical  aphonia  and  from  sim- 
ple oedema  glottidis. 

Treatment. — The  patient  should  breathe  warm,  pure, 
and  moist  air,  and  must  avoid  over-use  of  the  voice.  Cold 
applications  to  the  neck  are  often  of  great  service.  The 
following  prescriptions  are  of  use  in  allaying  the  cough : 

!^s.  Ammonii  chloridi,  .^iss  ; 

Mist,  glycyrrhizse  comp.,     5iv. — M. 
Sig.    A   teaspoonful  every  two   hours   in   a  wineglassful   of 
water  for  an  adult. 


CHRONIC  CATARRHAL    LARYNGITIS.  269 

]^.  Antimonii  et  potassii  tartrates,     gr.  -^^^  ; 
Codeiae,  gr.  \. — M. 

Ft.  chart.  No.  j. 
Sig.    One  every  two  or  three  hours  for  an  adult. 

The  inhalation  of  menthol  and  compound  tincture  of 
benzoin  is  of  great  service.  When  the  acute  stage  is  passed 
astringent  sprays  may  be  employed. 

Attacks  of  dyspnoea  in  children  are  to  be  treated  as  are 
those  of  spasmodic  laryngitis. 

CHRONIC  CATARRHAL  LARYNGITIS. 

Etiology. — This  condition  may  result  from  repeated  acute 
attacks,  from  breathing  irritating  dust  or  vapor,  from  excess- 
ive smoking,  and  from  over-use  of  the  voice ;  it  may  com- 
plicate chronic  bronchitis  and  pulmonary  phthisis.  The 
most  common  cause,  however,  is  chronic  nasal  and  pharyn- 
geal catarrh,  especially  if  the  nares  be  occluded  and  unfit  for 
proper  nose-breathing. 

Pathology. — The  mucous  membrane  of  the  larynx  is 
congested  and  thickened,  and  the  proper  motility  of  the 
vocal  cords  is  impaired.  Secretion  is  excessive  or  scanty 
and  tenacious. 

Symptoms. — There  is  a  tickling,  irritating  cough,  worse 
at  night  and  in  damp  weather.  The  voice  is  husky,  has  no 
"  reaching  power,"  and  may  at  times  be  lost  entirely.  Tick- 
ling sensations  in  the  larynx  cause  a  constant  desire  to  clear 
the  throat. 

Treatment. — The  first  thing  is  to  remove  the  cause  of  the 
laryngitis,  and  especially  to  direct  proper  treatment  to  nasal 
and  pharyngeal  catarrhal  conditions,  should  they  exist. 
Heated  rooms  and  impure  air  are  to  be  avoided,  smoking  is 
to  be  prohibited,  and  proper  exercise  in  the  open  air  is  to  be 
insisted  upon.  Mufflers  and  neck-handkerchiefs  .should  be 
avoided.  Of  great  service  are  astringent  sprays,  especially 
nitrate  of  silver  (gr.  x  :  5J).  Obstinate  cases  should  be 
referred  to  a  throat  specialist. 


2JO       M.lXrAL    OF   THE   rKACTICE    OF  MEDICINE. 

MEMBRANOUS  LARYNGITIS. 

Etiology  and  Synonym. — The  occurrence  of  a  mcm- 
branou.s  laryngitis  not  diphtheritic  in  its  nature  is  denied  by 
some  authors  ;  but  cases  undoubtedly  occur  in  which  the 
Klebs-Loefflcr  bacillus  cannot  be  demonstrated,  but  in 
which  streptococci  and  staphylococci  pla\'  a  causative  role. 
Further  bacterial  examinations,  however,  are  desirable  to 
place  these  cases  of  non-diphtheritic  membranous  laryn- 
gitis upon  a  firm  and  independent  basis.  Syiioiiym :  Mem- 
branous croup. 

The  pathology  is  practically  that  of  diphtheria  of  the 
lar}'nx,  except  that  the  deeper  tissues  are  not,  as  a  rule,  so 
extensively  infiltrated,  and  that  the  Klebs-Loeffler  bacilli 
are  not  present.  The  exudation  may  be  confined  to  the 
larynx,  or  it  may  spread  to  the  trachea  and  bronchi,  and 
more  rarely  to  the  pharynx,  the  palate,  and  the  tonsils. 
In  the  exudate  staph}^lococci  and  streptococci  are  found. 
The  disease  occurs  in  children  between  two  and  seven  years 
of  age  almost  exclusively. 

The  symptoms  of  the  non-diphtheritic  laryngitis  closdy 
resemble  those  of  the  diphtheritic  form,  but  they  lack  the 
extreme  prostration  so  characteristic  of  diphtheritic  toxaemia. 
The  points  of  differential  diagnosis  from  diphtheria  are  as 
follows:  (i)  The  patient  is  a  child  between  two  and  seven 
years  of  age  ;  (2)  there  is  no  history  of  exposure  to  diph- 
theria ;  (3)  the  patient  does  not  act  as  a  source  of  contagion 
to  others ;  (4)  albumin  and  casts  are  not  apt  to  be  found  in 
the  urine;  (5)  the  symptoms  are  those  of  laryngeal  obstruc- 
tion and  inflammation  rather  than  those  of  ob.struction,  pros- 
tration, and  sepsis  ;  (6)  the  lesion  occurs  in  a  primary  form 
in  the  larynx,  whereas  in  diphtheria  the  membrane  on  the 
larynx  is  almo.st  invariably  secondary  to  membrane  on  the 
pharynx,  the  tonsils,  or  the  palate;  (7)  cardiac  failure, 
peripheral  neuritis  with  paralysis,  and  nephritis  are  not 
observed  as  sequelze. 

Treatment. — Owing  to  the  necessary  uncertainty  of  diag- 
nosis, the  case  should  be  isolated  thoroughly  from  the  start, 
and  be  considered  as  diphtheria.     The  treatment  is  that  of 


TUBERCULAR   LAR  YNGIT/S. 


271 


laryngeal  diphtheria  in  every  particular,  except  that  pharyn- 
geal irrigation  need  not  be  insisted  upon. 

TUBERCULAR   LARYNGITIS. 

Etiology  and  Synonym. — Tubercular  infection  of  the 
larynx  is  almost  always  secondary  to  pulmonary  tuber- 
culosis, in  which  it  complicates  from  18  to  30  per  cent,  of  all 
cases.  The  larynx  may  be  involved  early  or  late  in  the 
course  of  the  pulmonary  disease.  The  occurrence  of  tuber- 
cular laryngitis  is  more  common  in  men  than  in  women, 
and  between  the  twentieth  and  thirtieth  years.  Synonym: 
Laryngeal  phthisis. 

Patholog-y. — The  mucosa  is  thickened  by  tubercular 
deposits  and  by  oedema,  especially  over  the  arytenoid  car- 
tilages. Tubercles  appear  upon  the  surface,  and  often  co- 
alesce to  form  masses,  which  may  ulcerate.  The  resulting 
ulcers  are  broad  and  shallow,  having  grayish  bases  and 
being  surrounded  by  thickened  mucosa.  There  may  be  a 
destruction  of  the  deeper  tissues  by  extension  of  the  ulcera- 
tion. The  disease  may  spread  to  the  pharynx,  the  epiglottis, 
or  the  oesophagus. 

Symptoms. — Hoarseness  or  aphonia  constitutes  an  early 
and  a  constant  symptom,  to  which,  however,  no  diagnostic 


Fig.  22. — Tubercular  laryngitis  (Brown). 

importance  can  be  attached,  as  the  change  of  voice  may  be 
due  to  muscular  insufficiency  of  the  vocal  cords  or  to 
chronic  catarrhal  laryngitis,  to  which  conditions  phthisical 
patients  are  extremely  susceptible.  There  is  usually  an 
annoying  painful  cough,  which  is,  however,  sometimes 
absent  even  in  aggravated  cases.  Pain  on  talking  may  be 
severe,  and  neuralgic  pains  running  to  the  ears  may  be  com- 


-/- 


M.lXr.lL    OF  THE   PRACTICE    OF  MEDIC/XE 


plained  of.  Pain  on  swallowing"  may  be  so  distressing  that 
the  patient  is  with  difificult}-  prevailed  upon  to  take  suffi- 
cient food  ;  this  pain  usuall>-  results  from  tubercular  involve- 
ment of  the  epiglottis  or  the  pharynx.  Dyspnoea  may 
appear  late  in  the  disease,  in  either  a  constant  or  a  parox- 
ysmal form,  often  necessitating  tracheotomy  to  avert  death 
from  suffocation  or  to  render  the  patient's  condition  a  trifle 
more  endurable. 

The  diag-nosis  is  made  by  laryngoscopic  examination. 
In  the  earlier  stages  of  the  disease  the  larynx  is  of  a  peculiar 
pallor,  while  the  arytenoids  show  a  characteristic  club-like 
swelling.  Later  in  the  disease  the  tubercular  masses  and 
ulcerations  are  easily  recognized.  A  diagnosis  is  aided  by 
finding  tubercular  changes  in  the  lungs,  and  is  rendered 
certain  by  the  presence  of  tubercle  bacilli  in  the  secretion 
from  the  base  of  the  ulcer. 

The  prognosis  for  duration  of  life  depends  largely  upon 
the  primary  pulmonary  disease.  Death  may  be  hastened  by 
suffocation,  inanition,  or  exhaustion. 

Treatment  is  often  unavailing.  The  larynx  should  be 
kept  free  of  secretion  by  cleansing  sprays.  Astringents 
may  be  used  by  spray  or  insufflation,  and  powdered  iodo- 
form may  be  insufflated  with  benefit.  Pain  in  swallowing 
may  be  controlled  by  spraying  the  throat  with  a  2  per 
cent,  solution  of  cocaine.  Applications  of  lactic  acid  and 
submucous  injections  of  creosote  have  been  recommended 
warmly,  but  they  should  be  used  only  by  skilled  specialists. 
For  the  relief  of  the  dyspnoea  tracheotomy  may  be  indicated. 
Surgical  treatment  of  tubercular  laryngitis  consists  in  the 
scraping  out  of  tubercular  deposits,  the  parts  being  exposed 
by  a  median  thyroidectomy  if  necessary. 

SYPHILITIC    LARYNGITIS. 

The  hereditary  form  of  syphilitic  laryngitis  usually  appears 
in  early  childhood ;  it  is  characterized  by  the  formation  of 
gummata,  deep  ulcerations,  and  cicatricial  deformities.  The 
acquired  form  is  more  common. 

As  a  secondary  lesion  the  larynx  may  be  the  seat  of  an 
erythema,  imparting  to  it  a  purplish-red,  mottled  appear- 


(EDEMATOUS  LARYNG/77S.  2/3 

ance  and  giving  rise  to  the  symptoms  of  a  simple  laryngitis. 
Mucous  patches  and  condylomata  are  rarely  observed. 

As  a  tertiary  lesion  the  disease  is  most  common.  There 
is  a  chronic  catarrhal  laryngitis,  with  an  infiltration  of  the 
mucosa  with  gummata  varying  in  size  from  a  pin's  head  to  a 
hazelnut.  These  gummata  may  undergo  resolution  if  the  ap- 
propriate treatment  be  effectual,  or  they  may  ulcerate,  fre- 
quently destroying  the  deeper  structures.  The  lesions  may 
involve  the  larynx  or  may  be  unilateral.  Cicatrices  follow  the 
ulcerations,  and  they  may  be  sufficiently  extensive  to  cause 
great  deformity.  Laryngeal  stenosis  from  such  a  cause  is  a 
frequent  sequela. 

Treatment  must  be  prompt  and  energetic — mercury  for  the 
secondary  form,  potassium  iodide  in  large  doses  for  the 
tertiary  period,  under  the  rules  laid  down  for  the  treatment 
of  syphilis.  The  larynx  must  be  kept  clear  by  sprays,  and 
any  resulting  stenosis  is  to  be  treated  by  cutting  or  by  dila- 
tation. Should  the  gummata  be  large  enough  to  occlude 
the  glottis,  tracheotomy  may  be  necessary  to  avert  fatal 
dyspnoea. 

(EDEMATOUS    LARYNGITIS. 

Etiology  and  Synonym. — CEdema  of  the  glottis  may 
complicate  severe  acute  inflammation,  whether  due  to  cold, 
to  inhalation  of  irritant  vapors,  or  secondary  to  certain  of 
the  acute  infectious  diseases.  It  may  occur  with  perichon- 
dritis, as  in  tubercular  or  syphilitic  laryngitis,  or  it  may  be 
due  to  the  spread  of  intense  inflammations  of  neighboring 
parts.  CEdema  of  the  glottis  may  suddenly  occur  in  the 
course  of  acute  or  chronic  Bright's  disease,  but  this  mode 
of  occurrence  is  exceedingly  rare.  Synonym  :  CEdema  of 
the  glottis. 

Symptoms. — Dyspnoea  is  suddenly  developed  and  be- 
comes rapidly  urgent.  The  voice  becomes  husky  and  is 
finally  lost.  Respiration  is  accompanied  by  stridor.  Symp- 
toms of  asphyxia  occur  as  a  terminal  event. 

The  diagnosis  can  be  made  with  certainty  by  laryngoscopic 
examination.  The  ary-epiglottidean  folds  are  seen  to  be 
intensely  oedematous,  meeting  in  the  median  line  in  severe 

18 


274        MANi'AL    OF   TJ/E    P A'. I C TICK    OF  MEDICINE. 

cases.  The  epiglottis  may  be  involved  by  the  cedema,  and  in 
rare  cases  the  parts  below  the  cords  are  also  swollen.  With- 
out the.  aid  of  the  laryngoscope  the  diagnosis  can  usually 
be  made  by  feeling  the  oedematous  parts  with  the  finger-tip. 

The  prognosis  is  exceedingly  bad. 

Treatment. — No  time  should  be  lost  in  temporizing.  Ice 
poultices  should  be  applied  to  the  neck,  and  after  spraying 
the  throat  with  cocaine  long  incisions  should  be  made  into 
the  oedematous  parts  with  a  curved  bistoury  protected  ex- 
cept at  the  extreme  tip.  Tracheotomy  should  be  resorted 
to  unless  prompt  relief  is  afforded  by  the  scarifications. 


2.  DISEASES  OF  THE  BRONCHI, 

ACUTE    CATARRHAL    BRONCHITIS. 

Etiology. — Primary  bronchitis  is  exceedingly  common 
as  the  result  of  "  catching  cold,"  beginning  as  a  coryza  and 
extending  downward  in  the  chest.  It  is  more  frequent  in 
children  and  old  people  than  in  adults,  and  in  the  aged 
is  a  formidable  disease.  Cases  are  more  common  in  the 
winter  and  spring  months  and  in  climates  in  which  extreme 
and  sudden  changes  in  the  weather  occur.  The  disease  is 
occasionally  seen  in  localized  epidemics,  and  it  may  even 
assume  an  apparently  contagious  nature.  Those  who  lead 
an  indoor  life  with  insufficient  ventilation  are  more  suscep- 
tible, and  those  with  "  delicate  chests  "  develop  the  disease 
upon  the  least  provocation.  It  may  be  caused  by  the  in- 
halation of  noxious  gases,  such  as  ammonia,  chlorine,  or 
sulphurous  acid,  or  by  the  breathing  of  smoke  or  of  dust, 
especially  in  factories. 

Scco7idary  bronchitis  occurs  with  measles,  influenza, 
whooping-cough,  and  any  of  the  infectious  diseases,  and 
with  diseases  of  the  heart,  lungs,  or  pleura.  The  considera- 
tion of  these  cases  is  referred  to  their  respective  headings. 

Pathology. — The  lesion  is  bilateral,  affecting  the  trachea 
and  the  larger  and  medium-sized  bronchi.  In  severe  cases, 
especially  in  children  and  old  people,  the  smaller  bronchi 
may  be  involved.     The   mucous  membrane  is  congested, 


ACUTE    CATARRHAL    BRONCI/mS  2/5 

reddened,  swollen,  and  covered  with  mucus  and  muco-pus 
containing  desquamated  epithelial  cells  and  leucocytes. 
The  mucous  glands  are  enlarged.  In  severe  cases  the  sub- 
mucosa  is  oedematous  and  is  infiltrated  with  leucocytes. 

Symptoms. — I)i  Adults. — There  may  be  chilly  feelings  at 
the  onset,  followed  by  moderate  fever,  which  rarely  rises  to 
103°  F.  even  in  the  severest  cases.  Heaviness  and  malaise 
are  present,  with  general  pains  in  the  bones,  and  the  patient 
may  be  sick  enough  to  be  in  bed. 

The  chest  symptoms  set  in  with  a  feeling  of  tightness  and 
oppression,  a  scraped  feeling  under  the  sternum,  and  a 
cough.  At  first  the  cough  is  dry,  hoarse,  and  painful,  com- 
ing in  distressing  paroxysms.  Pain  in  the  chest  during 
coughing  is  chiefly  felt  along  the  attachments  of  the  dia- 
phragm and  down  the  sternum.  When  secretion  is  estab- 
lished the  cough  is  much  relieved.  The  sputum  is  at  first 
scanty  and  mucous  in  character;  it  may  be  blood-streaked; 
later  it  becomes  more  abundant  and  muco-purulent.  Dysp- 
noea is  not  a  regular  feature  of  bronchitis  of  adults,  although 
in  some  patients  there  may  be  asthmatic  breathing. 

Bronchitis  /;/  young  children  is  a  more  serious  disease, 
from  its  tendency  to  involve  the  smaller  tubes  and  to  merge 
into  broncho-pneumonia.  In  young  babies  cough,  fever, 
and  rapid  breathing  may  be  the  only  symptoms.  The  rapid 
breathing  makes  it  difficult  to  nurse  these  young  infants. 
In  older  children  the  disease  may  be  either  mild  or  severe. 
In  severe  cases  there  may  be  convulsions  at  the  outset. 
The  fever  is  high  (102°  to  103°  F.)  with  morning  remis- 
sions ;  the  pulse  is  rapid ;  the  breathing  is  rapid  and  may  be 
insufficient,  as  shown  by  duskiness  of  the  skin  and  symptoms 
of  carbon-dioxide  poisoning.  There  is  cough,  but  the  sputa 
are  regularly  swallowed.  There  are  apt  to  be  gaseous  dis- 
tention of  the  stomach  and  vomiting.  It  is  often  hard  to 
tell  where  bronchitis  ends  and  broncho-pneumonia  begins. 
If  the  symptoms  be  severe,  if  they  continue  for  three  or  four 
days  without  improvement,  and  if  the  physical  signs  point  to 
the  involvement  of  the  smallest  bronchi,  it  is  best  to  regard 
the  case  as  one  of  pneumonia.     To  this  class  of  cases  the 


2/6        M.-iXC.iL    OF  THE   PRACTICE    OF  MEDICLYE. 

term  "  capillary  broncliitis  "  is  given,  but  they  are  more 
properly  cases  of  broncho-pneumonia. 

Bronchitis  /;/  old  people  is  dangerous  from  the  prostration 
and  from  the  tendency  of  the  disease  to  spread  to  the 
smaller  tubes,  and  even  to  pass  into  broncho-pneumonia. 
There  is  a  slight  but  irregular  fever ;  prostration  is  extreme, 
the  weakness  interfering  with  the  cough  and  the  proper 
clearing  out  of  the  accumulated  mucus.  There  is  no  com- 
plaint of  dyspnoea,  but  the  breathing  is  rapid  and  often  is 
insufficient.  There  may  be  slight  delirium,  especially  at 
night. 

Physical  Signs. — The  regular  physical  signs  of  bronchitis 
consist  of  coarse  large  and  small  mucous  rales.  In  children 
bronchial  fremitus  is  usually  present.  In  the  earlier  stages 
there  may  be  sibilant  and  sonorous  breathing.  Subcrepi- 
tant  rales  point  to  the  involvement  of  the  smaller  tubes. 
Rales  may  be  absent  (i)  in  mild  cases  with  scanty  secretion, 

(2)  in  inflammation  of  the  trachea  and  the  large  bronchi  alone, 

(3)  after  coughing  with  the  expulsion  of  the  secretion,  and 

(4)  in  the  feeble  and  aged,  in  whom  respiration  is  too  feeble 
to  generate  rales. 

The  prognosis  is  good  except  in  young  infants  and  in 
old  people,  in  whom  broncho-pneumonia  may  develop.  In 
the  aged  death  from  exhaustion  may  occur. 

The  diagnosis  of  bronchitis  is  simple,  but  it  is  not  to  be 
considered  complete  unless  it  be  determined  whether  the 
bronchitis  is  primary  or  is  dependent  upon  some  other 
disease,  or  whether  it  be  an  acute  exacerbation  of  a  chronic 
bronchitis.  Bronchitis  at  an  apex  implies  tubercular  disease. 
Bronchitis  of  the  finer  tubes,  worse  at  the  apex  and  with 
continual  high  temperature,  suggests  miliary  tuberculosis. 
Unilateral  bronchitis  suggests  aneurysmal  pressure,  chronic 
interstitial  pneumonia,  or  pleural  adhesions.  Bronchitis  with 
dyspnoea  and  repeated  slight  hemorrhages  suggests  tuber- 
culosis or  cardiac  disease.  Recurring  attacks  of  bronchitis 
in  young  children  suggest  tuberculosis  or  tubercular  bron- 
chial glands. 

Treatment. — In  the  majority  of  cases  no  treatment  is  re- 
quired.    Much  can  be  done  to  abort  an  attack  by  free  dia- 


ACUTE    CATARKII.lf.    /i A'()XC///77S.  277 

phoresis  at  the  onset.  A  Dover's  powder  at  night  with  a  hot 
.mustard  foot-bath  often  suffices.  A  hot  lemonade  contain- 
ing a  little  whiskey  is  a  popular  and  efficacious  remedy. 
Turkish  baths  are  objectionable  from  the  danger  of  catch- 
ing more  cold  on  leaving  the  bath-house,  but  a  hot  bath  at 
night  is  often  useful  if  the  patient  need  not  leave  the  house 
afterward.  The  bowels  should  be  opened  by  salines,  and  10 
grains  of  quinine  in  a  single  dose  may  be  given.  Delicate 
patients  should  be  kept  indoors  or  in  bed.  Expectorants 
are  very  useful  to  promote  free  secretion,  but  they  are  often 
given  indiscriminately.  They  may  be  combined  with  seda- 
tives. In  the  dry  stage  tartar  emetic  in  gr.  -^  doses  every 
two  hours  until  slight  nausea  is  experienced  is  often  service- 
able, but  preparations  of  squills,  senega,  ipecac,  or  ammo- 
nium muriate  may  be  used.  The  sedatives  employed  are 
codeia  and  dilute  hydrocyanic  acid  or  small  doses  of  opium. 
The  following  formula  is  recommended  : 

I^.  Codeiae,  gr.  \; 

Amnion,  muriat.,  gr.  ij  ; 

Acid,  hydrocyanic,  dilut.,     1T[  iij ; 
Syrup,  scillae  comp.,  TTL  x  ; 

Infus.  prun.  Virg.,  ad  3j. — M. 

Sig.    Dose  every  two  or  three  hours  for  an  adult. 

When  free  secretion  is  established,  ammonium  muriate  with 
mist,  glycyrrhizae  comp.  is  of  much  benefit.  The  paroxysmal 
cough  of  the  earlier  stages  is  frequentl}^  benefited  by  the 
inhalation  of  steam,  to  which  maybe  added  compound  tinc- 
ture of  benzoin  or  terebene.  If  the  disease  threaten  to 
become  chronic,  the  patient  should  be  put  upon  a  support- 
ing tonic  treatment,  and,  if  possible,  be  sent  away  to  some 
warm,  dry,  inland  place. 

Bronchitis  in  children  is  to  be  treated  like  that  in  adults, 
except  that  opiates  are  not  well  borne.  Severe  cases  are  to 
be  treated  like  broncho-pneumonia.  If  the  bronchi  become 
blocked  by  a  too  profuse  secretion,  interfering  with  free 
respiration,  a  simple  emetic  should  be  given.  Bronchitis  in 
old  people  frequently  requires  stimulation  by  alcohol,  digi- 


2/8        MAXL'.lf.    OF   THE   FRACIICE    OF  MEDICINE. 

talis,  and  strychnine.     Opiates  are  to  be  used  with  extreme 
caution. 

ACUTE  CROUPOUS  BRONCHITIS. 

Etiolog-y  and  Synonyms. —  The  disease  is  rare.  It  may 
occur  as  the  result  of  breathing  irritating  \-apors  and  steam, 
but  it  is  more  often  secondary  to  diphtheritic  or  croupous 
larj'ngitis  by  extension  downward.  Syiioin'iiis :  Acute 
fibrinous  bronchitis;  Acute  membranous  bronchitis;  Diph- 
theritic bronchitis. 

The  lesion  is  that  of  a  croupous  inflammation  of  a  mu- 
cous membrane.  In  cases  complicating  laryngeal  diphtheria 
tlie  Klebs-Loeffler  bacilli  are  present  in  the  membrane. 

Symptoms. — There  may  be  a  chill  with  fever  and  pros- 
tration at  the  onset,  or  there  may  be  the  previous  history 
of  membranous  laryngitis.  When  developed,  there  is  a 
cough  with  muco-purulent  expectoration.  From  time  to 
time  there  will  be  attacks  of  paroxysmal  cough  with  the 
expectoration  of  rolled-up  casts  of  a  bronchus  and  its 
branches.  These  casts  consist  chiefly  of  coagulated  fibrin 
which  in  places  has  undergone  hj'aline  degeneration,  and  in 
its  meshes  are  leucocytes,  epithelial  cells,  and  frequently  Ley- 
den's  crystals  and  Curschmann's  spirals.  These  casts  readily 
unroll  in  the  water.  During  the  coughing  attack  suffoca- 
tion seems  imminent,  and  often  some  blood  is  raised,  but 
after  the  cast  is  expectorated  the  distress  abates.  Between 
the  coughing  attacks  the  symptoms  resemble  severe  acute 
bronchitis,  frequently  with  symptoms  of  insufificient  aeration 
of  the  blood  and  of  dyspncea. 

The  physical  signs  consist  of  bronchial  rales  of  all  kinds, 
fine  and  coarse,  with  sibilant  and  sonorous  breathing. 
When  a  bronchus  is  occluded,  breathing  sounds  may  be 
absent  over  that  portion  of  lung,  returning,  however,  when 
the  occluding  membrane  is  coughed  up. 

The  prognosis  is  bad,  depending  on  the  nature  of  the 
primary  disease  and  the  extent  of  the  bronchi  involved. 
Death  usually  occurs  from  suffocation.  It  is  a  most  serious 
complication  after  tracheotomy. 


CI/RONIC   CATARIUIAl.    fiRONC/I/T/S.  2J<) 

The  treatment  is  that  of  acute  bronchitis,  except  that 
inhalation  of  steam  is  often  of  service  in  loosening  the  false 
membrane.  For  this  purpose  hypodermics  of  pilocarpine 
may  also  be  employed.  Inhalations  of  pure  oxygen  gas  are 
of  benefit  if  symptoms  of  asphyxia  appear. 

CHRONIC    CATARRHAL    BRONCHITIS. 

Etiolog-y. — Chronic  catarrhal  bronchitis  may  occur  after 
repeated  acute  attacks,  but  it  is  not  common  except  in  rheu- 
matic and  gouty  patients.  It  is  most  commonly  secondary 
to  emphysema,  to  any  chronic  inflammation  of  the  lung,  to 
pleural  adhesions,  and  to  organic  heart  disease.  .  It  usually 
occurs  in  elderly  people;  it  is  more  common  in  the  winter 
months. 

Patholog-y. — The  mucous  membrane  of  the  bronchi  may 
be  thinned,  and  the  muscular  and  glandular  coats  may  be 
either  atrophied  or  thickened  and  granular.  There  may  be 
superficial  ulcerations.  Bronchial  dilatation  is  not  uncom- 
mon.    Emphysema  is  usually  present. 

The  sjrmptonis  persist  for  years — better  in  summer,  worse 
in  winter.  There  is  a  cough  which  is  worse  at  night.  The 
expectoration  varies  greatly.  In  some  cases  it  is  scanty — 
the  so-called  "  dry  catarrh,"  an  obstinate  form  with  severe 
and  paroxysmal  cough.  The  term  "  bronchorrhoea  "  is  ap- 
plied to  cases  with  excessive  secretion.  The  expectoration 
may  be  thick  and  yellowish  or  greenish,  or  more  watery  in 
character,  depending  upon  the  relative  proportions  of  pus, 
mucus,  and  serum.  If  bronchiectatic  cavities  are  present, 
the  patient  will  often  raise  large  quantities  of  secretion  by 
any  change  of  position  which  allows  the  cavity  to  drain 
itself  Dyspnoea  is  not  marked  except  from  associated  em- 
physema or  cardiac  disease,  although  some  patients  develop 
asthmatic  breathing  from  time  to  time.  There  may  be  mild 
constitutional  symptoms,  especially  during  the  winter 
months — emaciation,  slight  afternoon  rise  of  temperature, 
and  loss  of  strength. 

Fetid  bronchitis  occurs  when  the  secretions  decompose, 
especially  in  bronchiectatic  cavities,  in  tubercular  cavities, 


280       MAXCAL    OF   THE   PRACTICE    OF  MFDICIXE. 

with  abscess  and  gangrene  of  the  lung,  and  in  empyema 
with  a  puhiionary  fistula. 

Fetid  expectoration  may  occur  in  chronic  bronchitis  ;  it 
is  likely  to  lead  to  bronchiectasis,  pneumonia,  or  gangrene 
of  the  lung.  In  these  cases  it  is  often  difficult  to  say  which 
is  the  primary  disease. 

'  The  physical  signs  are  those  of  bronchitis — coarse  and 
subcrepitant  rales,  with  sibilant  and  sonorous  breathing. 
Bronchiectatic  cavities  yield  their  regular  physical  signs. 
If  the  bronchitis  be  secondary  to  pulmonary  or  cardiac  dis- 
ease, the  ph\'sical  signs  of  such  disease  are  present. 

The  prognosis  is  bad  for  complete  recovery,  although 
patients  live  for  years  in  comparative  comfort. 

Treatment. — The  best  possible  treatment  is  to  send  the 
patient  for  the  winter  to  some  warm,  equable  climate.  In 
every  case  the  primary  disease  should  be  treated,  gouty  and 
rheumatic  habits  corrected,  the  bowels  regulated,  the  diet 
supervised,  and  every  attention  paid  to  the  general  nutrition. 
The  ordinary  expectorants  are  not  of  much  service.  Iodide 
of  potassium  in  5-  or  lo-grain  doses  three  times  a  day  often 
has  a  certain  curative  influence ;  it  should  always  be  tried. 
Ammonium  chloride  in  10-  or  15-grain  doses  every  two  or 
three  hours  does  good  when  the  secretion  is  abundant.  If 
there  be  profuse  purulent  secretion,  turpentine,  terpin  and 
terpin  hydrate,  cubebs,  and  oil  of  sandalwood  should  be 
tried.  For  distressing  cough  the  syrup  of  tar,  with  or  with- 
out the  syrup  of  wild  cherry  or  the  fluid  extract  of  chekan, 
may  be  used.  The  latter  is  to  be  given  in  oj  doses  every 
three  hours,  and  the  most  desirable  way  of  administering  it 
is  to  evaporate  it  to  a  solid  extract,  which  can  be  given  in 
capsule,  after  the  common  method  of  administering  War- 
burg's tincture. 

If  fetid  bronchitis  occurs,  myrtol  may  be  used  in  2-  to 
5-grain  doses  three  times  a  day.  Oil  of  sandalwood  and 
terpin  hydrate  are  also  of  service,  while  the  odor  may  be 
lessened  by  means  of  sprays  of  carbolic  acid  or  of  thymol. 


BK  O  NCI  I  IE  CTASIS. 


2«I 


CHRONIC    CROUPOUS   BRONCHITIS. 

Etiology  and  Synonyms. — Nothing  definite  is  known 
about  this  rare  disease,  except  that  it  is  more  common  in 
adults  and  in  males,  and  that  it 
is  often  associated  with  phthisis. 
Synonyms :  Membranous  bron- 
chitis ;  Fibrinous  bronchitis ; 
Plastic    bronchitis. 

The  symptoms  of  chronic 
bronchitis  are  present,  and  from 
time  to  time  the  patient  has  a 
severe  coughing  attack,  possibly 
with  spitting  of  blood,  and  raises 
a  cast  of  a  bronchus  and  its 
branches.  These  casts  consist 
of  an  unknown  albuminoid  sub- 
stance, probably  of  altered  fibrin.  The  attacks  occur  at 
varying  intervals  extending  over  years,  as  the  disease  is 
essentially  chronic. 

The  prognosis  for   life   is   good ;  for  recovery  from  the 
bronchitis,  bad. 

The  treatment  is  that  of  chronic  bronchitis. 


Fig.  23. — Fibrinous  bronchial   cast. 


BRONCHIECTASIS. 

Definition. — Bronchietasis  is  a  dilatation  of  the  bronchial 
tubes. 

Etiology. — The  disease  is  always  secondary  to  some 
lesion  weaking  the  bronchial  wall,  so  that  it  dilates  under 
coughing  pressure. 

1.  There  may  be  congenital  weakness  of  the  bronchial 
wall,  usually  unilateral,  but  these  cases  are  extremely  rare. 

2.  Inflammation  of  the  bronchial  wall  leading  to  atrophic 
changes  in  the  muscular  and  fibrous  structures  is  the  opera- 
tive cause  in  the  large  majority  of  cases;  hence  the  disease 
occurs  with  chronic  bronchitis,  emphysema,  broncho-pneu- 
monia of  children,  phthisis,  foreign  bodies  within  the 
bronchi,  or  pressure  from  an  aneurysm  or  a  tumor. 


282        M.I.M'AL    0J-'    THE    PRACTICE    OT  MEDICIXE. 

3.  The  bronchial  wall  may  be  weakened  by  traction  from 
without,  from  old  pleuritic  adhesions,  interstitial  pneumonia, 
and  fibroid  phthisis. 

Pathology. — A  cylindrical  and  a  sacculated  form  of  bron- 
chiectasis are  recognized.  The  two  forms  may  coexist  in 
the  same  lung.  The  dilatation  varies  in  size  from  a  pea  to 
that  of  a  small  orange.  Sacculated  dilatations  are  usually 
multiple,  being  spread  along  the  course  of  a  bronchus. 
A  single  sacculated  bronchiectasis  surrounded  by  non- 
indurated  lung-tissue  ma}'  occur  with  emphysema  and 
bronchitis  in  rare  instances,  and  may  resemble  a  single 
cyst  without  contents.  The  bronchial  wall  is  thinned  and 
its  constituent  elements  are  atrophied.  The  mucous  mem- 
brane constituting  the  lining  of  the  cavity  may  be  normal  or 
smooth  and  glistening,  the  columnar  having  been  replaced 
by  pavement  epithelium,  or  it  may  be  infiltrated  and  thick- 
ened, or  it  may  be  extensively  ulcerated,  especially  in  cases 
where  the  secretions  are  retained.  The  contents  of  some 
of  the  larger  cavities  are  often  exceedingly  fetid,  and  a 
general  fetid  bronchitis  may  complicate  the  disease. 

Symptoms. — Moderate  bronchiectasis  does  not,  as  a 
rule,  give  rise  to  symptoms  or  ph^'sical  signs,  and  it  cannot 
be  recognized  during  life.  The  larger  dilatations  are  diag- 
nosed by  the  cough  and  the  expectoration.  After  a  period 
of  some  hours  free  from  cough  a  paroxysm  will  occur,  dur- 
ing which  large  quantities  of  sputum  are  raised,  frequently 
"by  mouthfuls."  These  coughing  attacks  usually  occur  in 
the  morning  upon  arising;  they  may  be  brought  on  by 
any  position  of  the  body  that  allows  the  secretion  to  flow 
from  the  dilatation  into  a  normal  tube.  The  sputum  is 
abundant,  frequently  is  foul-smelling,  and  separates  on 
standing  into  three  layers — the  upper  of  a  brownish  froth, 
the  middle  of  watery  mucoid  substance,  and  the  lowest  of 
a  thick  sediment  of  granular  matter  and  cells.  When  ulcera- 
tion occurs  there  may  be  present  hasmatoidin-crystals  and 
elastic  fibres.     Hemorrhage  may  occur,  but  it  is  rare. 

The  physical  signs  are  not  pronounced  except  in  the 
well-marked  cases.  Large  saccular  "  dilatations  "  give  rise  to 
the  physical  signs  of  cavities,  associated  with  the  evidences 


ASTHMA.  283 

of  the  disease  to  which  the  bronchiectasis  is  secondary. 
The  caveroLis  signs  vary  from  time  to  time  according  to  the 
amount  of  accumulated  secretion ;  these  signs  are  often 
locaHzed  at  the  base  of  the  lung — a  point  of  considerable 
importance  in  the  diagnosis  between  this  lesion  and  a  tuber- 
cular cavity.  The  physical  signs  may  closely  resemble  a 
sacculated  empyema  with  an  opening  into  a  bronchus,  but 
the  history  of  the  case  will  usually  make  the  diagnosis  evi- 
dent. 

Prognosis. — The  condition  is  essentially  chronic,  often 
lasting  for  years,  during  which  time  the  patient  may  enjoy 
an  active  life.  The  prognosis  is  rendered  worse  by  the 
primary  lung  conditions,  by  hypertrophy  and  dilatation  of 
the  right  ventricle  secondary  to  interstitial  pneumonia,  and 
by  the  possibility  of  an  added  tubercular  infection  or  of 
pulmonary  gangrene. 

Treatment  is  unsatisfactory,  because  it  is  inadequate  to 
heal  the  dilatation.  The  cough  is  beneficial  in  clearing 
out  the  accumulated  secretions,  hence  narcotics  are  inadmis- 
sible. Stimulant  expectorants  are  useless.  Some  benefit 
may  result  from  the  administration  of  terpin  hydrate  in  full 
doses,  terebene,  and  turpentine.  Injection  of  antiseptic  solu- 
tions into  the  cavities  has  been  followed  by  good  results  in 
some  cases.  In  patients  in  good  condition,  with  superficial 
cavities,  incision  and  drainage  may  be  resorted  to.  For  the 
fever  myrtol  may  be  given  internally,  and  inhalation  of  car- 
bolic acid  (i  to  3  percent,  solution)  and  of  thymol  (i  :  looo), 
as  described  under  Fetid  Bronchitis ;  the  results,  however, 
are  never  very  satisfactory  in  extreme  cases. 

ASTHMA. 

Definition. — Asthma  is  an  affection  characterized  by 
paroxysmal  dyspnoea  due  to  contraction  of  the  bronchi. 
The  same  name  also  designates  the  paroxysmal  dyspnoea, 
due  .to  the  contraction  of  the  arteries,  commonly  seen  with 
emphysema. 

Etiolog-y. — A  number  of  theories  have  been  advanced  to 
explain  the  symptoms  :  (i)  That  the  disease  is  due  to  spasm 
of  the  muscular  tissue  of  the  small  bronchi  (Biermer).     (2) 


2 84       .V.IXCAL    OF  THE   PRACTICE    OF  MEDICINE. 

That  it  is  due  to  spasm  of  the  diaphragm  and  the  accessory 
muscles  of  respiration  (W'intrich-Bambcrger).  (3)  That  it 
is  a  vaso-motor  neurosis  causing  sudden  sweUing  of  tiie 
bronchial  mucous  membrane  (Storck,  Sir  Andrew  Clark, 
Traube).  (4)  That  it  is  due  to  the  elimination  of  Leyden's  , 
crystals.  (5)  That  it  is  a  special  form  of  inflammation  of 
the  bronchioles — bronchiolitis  exudativa  (Curschmann).  Of 
these  theories,  the  first,  that  of  bronchial  spasm,  is  the  one 
generally  adopted. 

The  causes  of  the  disease  are  both  predisposing  and 
exciting. 

Predisposing  Causes. — The  disease  is  more  common  in 
those  with  high-strung  nervous  systems  ;  it  may  run  in 
neurotic  families  associated  with  epilepsy  or  with  neuralgia. 
Males  are  more  frequently  affected  than  females.  As  to 
age,  of  225  cases,  71  occurred  in  the  first  decade,  30  in  the 
second,  39  in  the  third,  44  in  the  fourth,  24  in  the  fifth,  12 
in  the  sixth,  4  in  the  seventh,  and  i  in  the  eighth.  The 
predisposition  to  the  disease  is  frequently  retained  through- 
out life.  The  affection  is  more  common  in  those  with  pul- 
monary emphysema. 

Exciting  Causes. — Climatic  influences  are  very  curious, 
some  patients  having  asthma  in  some  places  and  not  in 
others,  without  apparent  reason.  Vegetable  and  terrestrial 
dust  and  irritating  vapors  may  induce  an  attack.  In  this 
respect  asthma  closely  resembles  hay  fever,  with  which  dis- 
ease it  is  closely  allied,  and  which  it  frequently  complicates. 
Ipecac,  sulphur,  iodine,  the  pollen  of  many  flowers  and 
grasses,  the  irritant  odor  of  violets,  roses,  and  strawberries, 
the  dust  of  feathers,  and  the  emanations  of  certain  animals 
afford  familiar  examples  of  personal  susceptibility.  Sudden 
mental  shocks  and  deep  emotions  may  induce  asthma.  The 
most  frequent  cause  of  an  attack  in  those  predisposed  to 
asthma  is  bronchitis,  and  if  in  such  patients  bronchitis  can 
be  avoided,  attacks  of  asthma  are  rare. 

Reflex  causes  arc  common.  Nasal  polypi,  hypertrophic 
rhinitis,  naso-pharyngeal  adenoids,  and  enlarged  tonsils  are 
frequently  found,  and  the  cure  of  these  conditions  will  in 
many  cases  remove  the  liability  to  asthma.     It  is  too  much 


ASTHMA. 


285 


to  claim  that  nasal  and  pharyngeal  lesions  comprise  the 
only  cause,  however,  as  has  been  done  by  some.  Among 
other  reflex  causes  are  uterine  and  ovarian  diseases,  over- 
loading of  the  stomach,  and  the  taking  of  certain  articles 
of  food. 

Pathology. — As  asthma  is  a  functional  disease,  there  is  no 
regular  lesion,  although  in  old  asthmatics  emphysema  and 
chronic  bronchitis  are  often  present. 

Symptoms. — There  may  be  premonitions — a  sense  of 
drowsiness,  depression  of  the  mind,  tightness  in  the  chest, 
or  peculiar  feelings  in  individual  cases  that  mean  an  impend- 
ing attack.  The  paroxysm  usually  begins  at  night  with  a 
sense  of  dyspnoea  and  with  laborious  efforts  at  breathing. 
The  patient  cannot  lie  down,  but  sits  or  stands,  usually  by 
an  open  window.  Inspiration  is  spasmodic ;  expiration  is 
prolonged  and  wheezing.  The  accessory  muscles  of  respi- 
ration are  called  into  play ;  the  face  is  livid  and  distressed, 
and  perhaps  cyanotic.  Limpid  urine  is  usually  passed  in 
large  quantities.  There  is  a  cough,  tight  at  first,  with  ball- 
like gelatinous  masses  of  sputum — the  "'perks''  of  Laennec. 
These  balls  can  be  unrolled  in  water;  they  represent  mucous 
casts  of  the  smaller  bronchi.  They  frequently  have  a  dis- 
tinct spiral  form,  and  they  are  known  as  "  Curschmann's 
spirals  "  (Fig.  24),  in  which  there  is   frequently  a  central 


Fig.  24. — Curschmann's  spirals  :  a,  central  fibre  (after  Curschmann). 

translucent  filament  composed  of  altered  mucin.     In  addi- 
tion are  found  in  the  sputum  the  pointed  octahedral  crystals 


286 


MAXUAL    OF   THE   PKACTICE    OF  MEDICINE. 


described  by  Lcyden,  identical  with  those  found  in  semen 
and  in  leukciemic  blood  (Fig.  25). 

Physical  Signs. — The  chest  is  fixed  and  enlarged — often 
from  6  to  8  centimeters  larger  in  circumference  than  nor- 
mal. Expansion  is  poor,  especially  laterally,  and  is  in 
strong  contrast  to  the  muscular  attempts  of  respiration. 
Inspiration  is  short ;  expiration  is  prolonged  and  wheezing. 
The  diaphragm  is  low  and  moves  but  slightly.  Percussion 
shows  an  increased  area  of  pulmonary  resonance.  The 
note  may  be  normal  or  hyper-resonant  or  tympanitic.  On 
auscultation  are  heard  all  varieties  of  sibilant,  sonorous, 
cooing,   and   whistling   rales,  especially   during    expiration. 


Fig.  25. — Charcot-Leyden's  asthma-crystals  (after  Riegel). 

The  expiratory  murmur  may  be  prolonged,  or  breathing 
sounds  may  be  absent  or  be  obscured  by  the  rales. 

The  duration  of  the  attack  varies  from  several  hours  to  a 
number  of  days.  In  the  more  protracted  cases  the  symp- 
toms are  worse  at  night.  Between  the  attacks  there  may 
be  dyspnoea,  wheezing  respiration,  and  cough.  In  the  long- 
standing cases  emphysema  and  chronic  bronchitis  develop, 
resulting  in  chronic  invalidism. 

The  prognosis  for  life  is  good,  death  never  resulting  dur- 
ing a  paroxysm. 


ASTJJMA.  287 

Treatment. — Djiring  the  attack  immediate  treatment  is 
required  to  relax  the  contracted  bronchioles.  A  number  of 
remedies  maybe  employed,  Of  these  remedies  amyl  nitrite 
is  the  most  serviceable,  a  perle  containing  from  2  to  5  minims 
being  broken  in  a  handkerchief  and  the  vapor  inhaled.  Hot 
stimulants  or  spirits  of  chloroform  in  hot  water  may  be 
given,  while  whiffs  of  chloroform  may  be  required  in  aggra- 
vated cases.  Permanent  relief  is  often  afforded,  even  in 
obstinate  cases,  by  a  hypodermic  injection  of  morphine. 
Nitroglycerin,  gr.  j-^  every  two  or  three  hours,  is  of  service 
in  the  more  protracted  cases.  Choral  in  10-  or  15-grain 
doses  often  affords  relief  Antipyrine,  gr.  xv,  or  phenacetine, 
gr.  X,  may  be  used,  repeated  every  three  hours.  Good 
results  are  claimed  for  the  fluid  extract  of  grindelia  robusta 
in  3j  doses  every  four  hours.  The  smoke  of  cigarettes 
containing  hyoscyamus,  belladonna,  or  stramonium  may  be 
inhaled,  or  pastilles  may  be  made  from  these  drugs,  with 
the  addition  of  potassium  chlorate  or  nitrate.  Inhalations 
of  cigar-smoke  are  frequently  of  great  value.  Paper  satu- 
rated with  a  strong  solution  of  potassium  nitrate  burnt 
in  the  room  before  retiring  will  often  ward  off  a  nocturnal 
attack. 

Between  attacks  antispasmodics  should  be  given.  Iodide 
of  potassium  in  gr.  v-xv  doses  three  times  a  day,  with  or 
without  the  addition  of  5  grains  of  chloral  to  each  dose,  is 
of  great  benefit.  Nitroglycerin,  gr.  y^Q-  every  four  to  six 
hours,  may  be  used.  The  systematic  inhalation  of  com- 
pressed air  has  been  recommended  strongly. 

The  diet  should  be  such  as  not  to  induce  flatulence, 
carbohydrates  being  used  in  great  moderation.  The  patient 
should  not  retire  to  bed  on  a  full  stomach,  and  it  is  usually 
best  for  the  heavy  meal  of  the  day  to  be  taken  at  noon. 

If  nasal  polypi  or  hypertrophies  are  present,  they  should 
be  removed. 

For  every  asthmatic  there  are  localities  in  which  he  has 
little  or  no  asthma.  The  particular  locality  of  exemption 
should  be  found  by  each  patient  to  suit  his  individual  case, 
as  no  regular  rule  can  be  laid  down  to  suit  all  patients. 


2S8        M.-IXCAL    OF   THE   PRACTICE    OF  MEDICINE. 

3.  DISEASES  OF  THE  LUNGS. 

{(.i)  Circulatory  Disturhances. 

CONGESTION    OF    THE    LUNGS. 

Congestion  may  be  either  active  or  passive. 

Active  congestion  occurs  with  acute  inflammation  of  the 
lungs,  with  over-action  of  the  heart,  and  from  the  inhalation 
of  hot  or  irritating  vapors.  It  may  cause  increase  of  dysp- 
noea, cough,  and  expectoration,  with  a  moderate  degree  of 
fever,  but  about  its  symptomatology  not  much  is  accurately 
known. 

Most  authors  describe  a  rapidly  fatal  form  of  congestion 
occurring  after  exposure  to  cold  or  after  over-exertion. 

Passiz'c  Congestion. — Two  distinct  forms  of  passive  con- 
gestion are  recognized — mechanical  and  hypostatic. 

1.  Mechanical  congestion  is  known  as  "  brown  induration  " 
or  the  "  pneumonia  of  heart  disease  "  ;  it  is  described  under 
the  heading  of  Chronic  Venous  Congestions  of  Heart 
Disease,  page   192. 

2.  Hypostatic  congestion  of  the  posterior  portions  of  the 
lungs  is  often  found  as  the  result  of  post-mortem  changes. 
It  is  common  in  those  confined  to  bed  for  a  long  time  in  a 
weakly  condition,  as  the  combined  result  of  feeble  circula- 
tion and  the  effect  of  gravity.  In  coma  and  in  cerebral 
injuries,  such  as  cerebral  hemorrhage,  it  is  often  seen  in  its 
most  pronounced  degree.  The  affected  portions  of  lung  are 
congested,  cedematous,  heavy,  and  imperfectly  aerated. 

The  congestion  may  be  complicated  by  patches  of  con- 
solidation resembling  either  broncho-pneumonia  or  a  lobar 
pneumonia,  being  due  to  the  passage  into  the  bronchi  of 
food  or  air  containing  streptococci. 

The  symptoms  are  usually  obscured  by  those  of  the 
primary  disease,  so  that  a  diagnosis  is  to  be  made  by  phys- 
ical signs.  There  is  dulness  over  the  congested  portions, 
with  feeble  breathing  and  liquid  rales.  In  more  advanced 
cases  there  may  be  bronchial  breathing  and  bronchophony. 


(KDJiMA    OJ<    TI/E   LUNGS.  289 

CEDBMA   OP    THE    LUNGS. 

Localized  oedema  of  the  lung.s  occurs  with  congestion, 
inflammation,  and  new  growths  ;  it  is  known  as  "  collateral 
oedema." 

General  pulmonary  oedema  occurs  from  weakness  of  the 
left  side  of  the  heart,  the  force  of  the  right  heart  being 
unimpaired,  or  it  may  occur  in  pronounced  conditions  of 
hydra^mia.  Either  cause  alone  may  suffice  for  its  produc- 
tion, although  in  extreme  cases  both  factors  are  usually 
present.  It  is  often  present  during  the  death  agony,  being 
a  symptom  of  approaching  death.  It  is  seen  in  the  final 
stages  of  cachexias,  profound  anaemia,  acute  and  chronic 
Bright's  disease,  pneumonia,  cerebral  diseases,  and  diseases 
of  the  heart. 

The  lungs  are  heavy,  pit  on  pressure,  and  from  their  cut 
section  exudes  a  frothy  serous  or  sero-sanguinolent  fluid  in 
abundance.  This  fluid  is  also  present  in  the  trachea  and 
the  bronchi.  The  oedema  interferes  with  the  proper  degree 
of  aeration,  although  cut  pieces  of  the  lung  still  float  in  water. 
There  is  usually  associated  congestion  of  the  lungs,  espe- 
cially of  the  posterior  portions. 

The  symptoms  are  increasing  frequency  of  respirations, 
dyspnoea  with  cough,  and  the  expectoration  of  serum  which 
may  be  blood-tinged.  The  respirations  are  bubbling  and 
rattling,  and  cyanosis,  increasing  coma,  and  cold,  clammy 
extremities  precede  the  fatal  issue.  The  percussion-note 
over  the  oedematous  portions  is  more  or  less  dull ;  the  respi- 
ratory murmur  is  feeble  or  is  obscured  by  large  liquid  rales 
and  bubbling  sounds  usually  first  heard  at  the  bases. 

The  treatment  is  that  of  the  primary  condition.  The  heart 
should  be  stimulated  energetically ;  cups  and  poultices  are 
to  be  applied  to  the  chest,  and  the  bowels  should  be  moved 
freely.  Venesection  should  be  resorted  to  in  acute  cases 
with  cyanosis ;  it  frequently  affords  relief 

19 


390        MAXCJL    OF   THE   PRACTICE    OF  MEDICIXE. 

PULMONARY   HEMORRHAGE. 

Two  forms  of  pulnionar)'  hemorrhage  are  recognized: 
I.  Broncho-puhiionary  hemorrhage,  or  bronchorrhagia,  in 
which  condition  the  blood  is  poured  into  the  bronchi  and 
is  expectorated;  2.  Puhiionar\'  apoplexy,  or  pneumorrhagia, 
in  which  disease  the  hemorrhage  occurs  into  the  substance 
of  the  lung. 

Broncho-Pulmonary  Hemorrhage,  or  Hemoptysis. 

There  is  a  variety  of  causes  giving  rise  to  this  condition. 

{a)  Pulmonary  tuberculosis  is  the  most  common  cause, 
and  it  should  always  be  suspected,  even  if  neither  symptoms 
nor  ph)-sical  signs  be  present.  Small  repeated  hemorrhages 
in  the  earlier  stages  are  due  to  bronchial  congestion  or 
ulceration.  Large  hemorrhages  in  the  later  stages  arise  in 
cavities  from  erosion  of  a  branch  of  the  pulmonary  artery 
or  from  rupture  of  an  aneurysmal  dilatation  of  the  same. 

{B)  Hemorrhages  may  occur  in  young  people  without 
assignable  cause,  although  in  some  cases  they  may  follow 
excitement  or  severe  muscular  exertion,  especially  in  high 
altitudes. 

(c)  Anaemic  hysterical  women  may  raise  a  little  blood 
from  time  to  time  without  apparent  reason.  Deception 
must  always  be  suspected  in  such  cases,  however. 

{d)  Severe  injuries  and  contusions  of  the  chest  are  often 
followed  by  hemorrhage. 

(r)  Patients  with  emphysema  and  bronchitis  may  occa- 
sionally raise  small  quantities  of  blood. 

(/")  Hemorrhage  may  result  from  certain  diseases  of  the 
lung,  the  initial  stage  of  pneumonia,  cancer,  gangrene, 
abscess,  or  bronchiectatic   cavities. 

(^)  Vicarious  haemoptysis  may  occur  with  interrupted 
menstruation.  It  has  been  known  to  follow  removal  of 
both  ovaries. 

(//)  Small  repeated  hemorrhages  are  common  with  the 
pulmonary  congestion  of  heart  disease,  especially  with 
lesions  of  the  mitral  valve. 

(z)  With  aneurysms  small  quantities  of  blood  may  be  raised 


PULMONARY  IfKMOR R IJAG E.  2Cj] 

from  congestion  of  the  bronchi  from  pressure  or  by  leakage 
through  a  small  perforation.  Large  and  fatal  hemorrhage 
results  from  rupture  of  the  sac  into  the  trachea  or  into  a 
bronchus. 

(y)  Any  ulcerative  process  in  the  larynx,  the  trachea,  or 
the  bronchus  may  cause  small  repeated  hemorrhages. 

(/')  Sir  Andrew  Clark  describes  a  form  of  haemoptysis, 
seen  in  elderly  people,  which  he  calls  "  arthritic  haemop- 
tysis." It  occurs  in  those  of  the  arthritic  diathesis ;  it  is 
due  to  minute  structural  alterations  in  the  terminal  blood- 
vessels of  the  lung.  The  prognosis  in  these  cases  is  usually 
good. 

(/)  Haemoptysis  occurs  with  extensive  blood-alterations 
of  malignant  fevers,  as  hemorrhagic  variola,  and  with  pur- 
pura haemorrhagica. 

(pi)  In  Japan  and  China  occurs  an  endemic  haemoptysis 
due  to  the  presence  of  the  Distoma  Ringeri  in  the  bronchi. 

Symptoms. — There  may  be  a  preceding  feeling  of  oppres- 
sion in  the  chest,  but  usually  the  first  symptoms  are  a  warm, 
mawkish  taste  in  the  mouth,  nausea  and  faintness,  and  the 
appearance  of  the  blood.  The  quantity  of  blood  ejected 
varies  from  a  dram  to  a  pint  or  more. 

Anaemic  symptoms — faintness,  syncope,  dyspnoea,  "  air- 
hunger,"  and  pallor — depend  on  the  quantity  of  blood  lost. 
Large  hemorrhages  may  be  fatal  from  anaemia  or  from  the 
filling  of  the  bronchi  with  blood,  but  usually  danger  is 
not  imminent.  There  is  generally  but  little  effort  in  raising 
the  blood.  Should  the  quantity  be  large,  a  certain  amount 
may  be  swallowed,  to  be  vomited  later  or  passed  with  the 
stools.  Blood  from  the  lungs  has  certain  characteristics 
which  distinguish  it  from  blood  from  the  stomach.  It  is 
scarlet  in  color,  of  an  alkaline  reaction,  frothy,  and  mixed 
with  mucus.  In  the  clots  air-bubbles  can  usually  be  seen. 
After  a  hemorrhage  the  sputa  are  usually  blood-stained,  of 
a  dark  crimson  or  brown  color,  and  frequently  clots  like 
bronchial  casts  are  raised.  Vomited  blood  is  dark  brown- 
ish, contains  no  air,  but  is  mixed  with  stomach-contents 
and  is  of  an  acid  reaction.  Blood  coming  from  the  pharynx 
or  the  nares  is  usually  hawked  up,  and  on  inspection  blood- 


292        .U.I. VI  .  I/.    OF   THE    PR.ICTICE    OF  .MF.D/CLXK. 

streaks  can  almost  al\va\-s  be  scon  descendini^  from  tlie 
naso-pharynx. 

Lar^  hemorrhages,  leading;  even  to  a  fatal  issue,  can 
take  place  into  extensive  pulmonary  cavities  without  blood 
being  coughed  up  at  all.  The  hemorrhage  may  continue 
for  several  hours  or  even  days,  and  attacks  may  be  repeated 
from  time  to  time.  They  may  be  induced  by  exertion,  by 
over-indulgence  in  stimulants,  or  by  excitement,  but  in 
some  cases  they  occur  without  apparent  cause,  even  while 
the  patient  is  resting  quietly  at  night. 

Anaemic  symptoms  follow  large  hemorrhages,  but  after 
small  hemoptyses  the  patients  frequently  feel  much  relieved 
in  their  pulmonary  or  cardiac  symptoms. 

Treatment. — For  the  large  hemorrhages  arising  from 
erosion  of  an  artery  or  from  rupture  of  an  aneurysm  treat- 
ment is  unavailing.  The  patient  should  be  kept  absolutely 
quiet  and  secluded,  and  small  doses  of  opium  should  be 
given  to  relieve  the  restlessness  and  steady  the  heart. 
Fainting  is  nature's  measure  of  tranquillizing  the  circulation 
and  inducing  firm  thrombosis. 

Anaemic  symptoms  are  treated  by  elevation  of  the  foot 
of  the  bed,  by  ligating  the  extremities,  and  by  hypodermic 
injections  (hypodermoclysis)  or  arterial  transfusion  of  ster- 
ilized saline  solutions,  which  may  also  be  given  by  the 
rectum.     Internal  haemostatics  are  useless. 

In  less  serious  hemorrhages  the  patient  may  be  given  ice 
to  swallow  and  may  drink  small  quantities  of  aromatic  sul- 
phuric acid  in  water.  Theoretically,  measures  to  reduce  the 
frequency  of  the  heart-beats  and  reduce  the  blood-pressure 
in  the  pulmonary  circulation  are  indicated,  but  our  know- 
ledge as  to  how  this  latter  indication  can  be  fulfilled  is  very 
meagre.  Rest  should  be  enforced,  and  opium  be  given  to 
quiet  the  patient.  The  diet  should  be  light,  and  stimulants 
should  not  be  employed.  Digitalis  is  contraindicated.  Aco- 
nite may  be  given  with  benefit  if  there  be  vascular  excite- 
ment. Acid  drinks  and  cracked  ice  may  be  given.  Ergot, 
gallic  acid,  acetate  of  lead,  hydrastis,  and  krameria  are  used 
as  routine  measures,  but  are  of  doubtful  utility.  Ice  applied 
to  the  chest  is  recommended,  and   in  some  cases  it  seems 


PULMONARY  HEMORRHAGE.  293 

to  do  good.     Free  purgation  is  indicated  to  reduce  blood- 
pressure  ;  it  should  be  resorted  to  in  all  protracted  cases. 

Pulmonary  Apoplexy  ;  Hemorrhagic  Infarct. 

Hemorrhage  into  the  substance  of  the  lung,  with  rupture 
of  its  tissue,  may  occur  with  severe  contusions,  with  pene- 
trating wounds,  and  with  rupture  of  an  aneurysm.  Aside 
from  these  cases,  so-called  "  hemorrhagic  infarct.^ "  result 
from  embolism  or  thombosis  of  a  branch  of  the  pulmonary 
artery,  resulting  in  the  stoppage  of  its  circulation.  As  these 
are  "  terminal "  arteries,  without  anastomotic  branches,  the 
blood  in  the  vessels  beyond  the  obstruction  is  in  a  condition 
of  stasis,  and  congestion  occurs  from  a  backward  pressure 
into  the  shut-off  region.  The  vascular  walls  lose  their  con- 
sistency and  allow  the  escape  of  blood  into  the  surrounding 
structures. 

The  hemorrhagic  area  is  red  and  solid,  resembling  a  blood- 
clot,  becoming  reddish-brown  in  time  from  pigment-changes. 
It  is  of  a  wedge  shape  with  the  base  out ;  the  pleura  covering 
it  is  usually  inflamed.  It  is  usually  situated  toward  the  base, 
and  it  varies  in  size  from  a  walnut  to  that  of  an  orange. 
There  may  be  a  surrounding  zone  of  pneumonia.  Such  an 
infarction  may  be  absorbed  if  small,  but  it  usually  becomes 
changed  to  a  pigmented,  puckered  cicatrix.  In  rarer  cases 
it  may  undergo  sloughing  or  gangrene.  Abscess  results  if 
the  cause  be  an  infectious  embolus  containing  suppurative 
micrococci,  as  may  occur  in  pyaemia  or  in  malignant  endo- 
carditis. 

Symptoms. — There  is  usually  pain  in  the  side,  sudden 
dyspnoea,  oppression  in  the  chest,  and  bloody  expectora- 
tion, in  some  cases  amounting  to  a  fair-sized  haemoptysis. 
Physical  examination  yields  over  the  hemorrhagic  area,  if  it 
be  of  sufficient  size,  dulness,  bronchial  voice  and  breathing, 
and  pleuritic  and  bronchial  rales.  Large  hemorrhagic  in- 
farcts may  be  followed  by  sudden  death.  It  must  be  remem- 
bered that  obstruction  of  a  large  branch  of  the  pulmonary 
artery  can  occur  without  the  formation  of  a  hemorrhagic 
infarct. 

The  treatment  is  practically  that  of  pneumonia. 


294        .y-l\L:t/.    OF   THE   PRACTICr.    OF  MEDJC/XE. 

LOBAR   PNEUMONIA. 

Definition  and  Synonyms. — Lobar  pneumonia  is  an  in- 
fectious disease  due  to  the  diplococcus  pneumoniae ;  it  is 
characterized  by  an  inflammation  of  the  lung  with  consti- 
tutional symptoms.  Synonyms:  Croupous  or  Fibrinous 
Pneumonia ;    Pneumonitis. 

Etiology. — The  diplococcus  pneumoniae  of  Frankel, 
commonly  known  as  the  "  pneumococcus,"  is  the  specific 
germ  of  the  disease.  It  is  an  ovoid  coccus,  or,  more  prop- 
erly speaking,  a  bacillus,  usually  occurring  in  pairs,  and  more 
often  encapsulated.  It  is  found  in  the  nasal  and  buccal 
secretions  of  20  per  cent,  of  healthy  people,  anil  after  an 
attack  of  pneumonia  it  is  often  found  in  the  mouth  for 
months  ;  hence  there  must  be  conditions  giving  the  germ  at 
times  more  intense  pathogenic  properties,  or  conditions  ren- 


■^- 


Fig.   26. — Fraiikel's  pneumonia  coccus,  bred  from  the  expectoration.     (Prepared  by  Prof. 
Gartner.     Oil-immersion  lens  j'j  ;  eye-piece  No.  4.) 

daring  the  individual  susceptible  to  the  infection.  Among 
these  causes  may  be  mentioned  exposure  to  hardship  and 
cold ;  consequently  the  disease  is  more  frequent  in  men 
than  in  women.  It  frequently  follows  immersion  in  cold 
water.  Traumatisms  of  the  chest-wall  produce  the  so-called 
"contusion-pneumonia."  Alcoholism,  chronic  Bright's 
disease,  and  any  condition  of  bodily  weakness  predispose 
to  the  disease.  Repeated  attacks  may  occur;  they  are  ex- 
plained by  auto-infection  from  the  persistence  of  diplococci 
in  the  buccal  and  nasal  secretions.  The  disease  is  more 
common  in  the  months  from  February  to  May,  although  it 
may  occur  at  any  time.  It  occurs  in  all  temperate  climates, 
but  it  is  unknown  north  of  Labrador.     It  is  more  frequent  in 


LOBAR   PNEUMONIA.  2g$ 

the  Southern  than  in  the  Northern  States.  The  influence  of 
age  is  important.  Liability  to  the  disease  increases  up  to 
the  twentieth  year,  then  decreases  until  liability  is  again 
increased  in  old  age.  Children  under  five  years  of  age 
usually  have  broncho-pneumonia;  those  between  five  and 
fifteen  years  of  age  have  either  lobar  pneumonia  or  broncho- 
pneumonia; adults  usually  have  lobar  pneumonia. 

The  diplococci  are  found  not  only  in  the  exudate  in  the 
inflamed  lung,  but  also  in  many  of  the  complicating  lesions, 
as  in  the  meninges,  the  pleura,  or  the  pericardium  ;  they  may 
even  involve  these  parts  without  there  being  any  inflamma- 
tion of  the  lung  at  all. 

Pathology. — The  lesion  involves  a  whole  lobe,  a  part  of 
a  lobe,  or  the  entire  lung.  The  lower  lobes  are  more 
frequently  involved  than  the  upper ;  the  right  lung  is  more 
often  involved  than  the  left.  The  process  is  divided  into 
four  stages  :  congestion,  red  hepatization,  gray  hepatization, 
and  resolution. 

Congestion. — The  lung  is  congested  and  heavy ;  its  cut 
surface  is  bathed  with  bloody  serum.  Microscopic  exami- 
nation shows  congestion  of  the  blood-vessels  and  swelling 
and  proliferation  of  the  alveolar  epithelium,  while  the  air- 
cells  are  partially  filled  by  an  exudate  of  fibrin  pus-cells, 
red  blood-corpuscles,  and  epithelial  cells.  The  stage  of 
congestion  usually  lasts  for  several  hours,  but  it  may  be 
protracted  for  several  days. 

Red  Hepatization. — The  lung  is  large,  often  showing  in- 
dentations of  the  ribs,  and  is  remarkably  friable.  It  is  hard 
and  airless,  cut  pieces  sinking  in  water.  There  is  fibrin  on  the 
pulmonary  pleura.  The  cut  surface  is  dry,  reddish,  and  dis- 
tinctly granular,  due  to  the  protrusion  of  inflammatory  exu- 
date from  the  air-cells.  The  microscope  shows  the  air-cells, 
and  frequently  the  small  bronchi  as  well,  filled  with  an  exu- 
date of  fibrin,  pus-cells,  red  blood-cells,  and  epithelium. 
The  blood-vessels  are  congested  but  pervious.  The  inter- 
stitial connective  tissue  of  the  lung  may  be  infiltrated  with 
inflammatory  exudate.  Diplococci,  and  occasionally  staph- 
ylococci and  streptococci  as  well,  are  seen  in  the  exudate. 


296        M.LXlilL    OF   THE   PRACTICE    OF  MEDICIXE. 

One-fourth  of  the  flital  cases  occur  in  rod  hepatization  from 
the  first  to  the  eleventh  da)-  of  the  disease. 

Gra\'^  HcpatiacJtioii. — Tlie  color  changes  from  reddish- 
brown  to  ijray,  at  first  in  spots,  so  that  the  luntj  has  a  mot- 
tled appearance.  The  lung  still  remains  solid,  but  the 
exudate  is  decolorized  and  begins  to  soften  and  degenerate. 
One-half  the  fatal  cases  occur  in  the  mottled  condition, 
between  the  second  and  the  eighteenth  day,  and  one-fourth 
in  the  completed  gray  stage,  between  the  fourth  and  the 
twenty- fifth  day. 

Rt'solittion  occurs  in  spots  at  first.  Fatty  degeneration 
and  liquefaction  of  the  exudate  occur,  allowing  of  its  absorp- 
tion and  expectoration.  Resolution  should  begin  soon  after 
defervescence,  but  it  may  be  delayed. 

The  unaffected  portion  of  the  lung  ma}-  be  congested  and 
oedematous,  especially  the  portions  near  the  affected  area. 
The  bronchi  of  the  pneumonic  lobe  show  catarrhal  inflam- 
mation, and  they  may  be  filled  by  fibrinous  plugs. 

Modifications  of  tlic  Lesion. — Resolution  may  be  delayed, 
the  lung  remaining  in  dry  gray  hepatization  for  weeks.  The 
exudate  may  be  so  excessive  that  the  blood-vessels  are 
compressed,  leading  to  necrotic  changes  of  portions  of  the 
lungs.  There  may  be  an  excessive  production  of  pus-ccUs, 
which  infiltrate  the  connective-tissue  septa,  forming  small 
abscesses  or  a  diffused  suppuration.  Gangrene  of  the  lung 
may  occur.  Instead  of  resolution  the  exudation  may  be- 
come organized  into  connective  tissue,  so  that  the  air-cells 
are  obliterated  and  rendered  permanently  unfit  for  use.  The 
bronchitis  may  be  general  and  excessive,  especially  in  cases 
accompanying  epidemic  influenza. 

Complicating  lesions  result  from  infection  of  other  parts 
by  diploccoci.  Pleuri.sy  is  only  to  be  considered  a  compli- 
cation if  it  extend  beyond  the  pneumonic  area  or  if  serous 
or  purulent  effusion  occur. 

Pericarditis  is  not  infrequent.  It  occurs  more  commonly 
with  double  or  left-lung  pneumonias  and  in  children.  It  is 
due  to  diplococcus  infection,  producing  plastic  inflammation 
or  serous  or  purulent  effusion.     The  prognosis  of  pleurisy 


LOIJAR   PNEUMONIA. 


I'l.AlK  19 


Day  of 
Disease 

2 

3 

4 

5 

6 

7 

R 

D 

10 

Pillae 

; 

120     104° 

/ 

A 

^ 

i    / 

'. 

Resp. 

*^0    110    103^ 

/ 

\ 

V 

f 

si/ 

;^ 

^ 

/^ 

w 

50   100    102*^ 

:\ 

\j 

7 

^ 

T 

f: 

V 

r\ 

• 

I 

\ 

40      90    101^ 

< 

1 

/ 

A 

I  •, 

^ 

•  •, 

\; 

i 

'■ 

30      80    100"^ 

■\ 

\- 

> 

y 

/> 

s/ 

V 

Vl 

s-S 

^ 

20      70      99' 

y 

;\ 

^ 

^: 

10      60      98'' 

'■ 

\ 

y 

/ 

Lobfir  pneumonia  terminating  by  crisis  on  the  seventh  day:   temperature  (black),  pulse 
(blue),  and  respiration  (red). 


Day  of 
Disease 

2 

3 

4 

5 

G 

7 

Pulse 

150    107° 

; 

t- 

140    106° 

A 

\ 

ED, 

130    105° 

:; 

/; 

120    104° 

'■ 

\ 

•( 

t\ 

I 

^ 

Resp. 

60     110    103° 

■/ 

\ 

/i 

^ 

•4 

c^ 

1/ 

r 

; 

• 

: 

50      100    102° 
40       90     101° 
30       80    100° 

V 

\/ 

■  1 

A 

A 

\ 

) 

/:N 

J 

: 

■> 

'■/ 

Sv 

^ 

s 

/ 

\ 

h 

: 

Temperature  chart  of  a  fatal  case  of  pneumonia  :    temperature  (blaclc),  pulse   (blue),  and 
respiration  (red). 


/,  DBA  R   PNE  UMON/A. 


297 


;ind  pericarditis  of  pneumonic  origin  is  better  tlian  thjit  of 
the  other  forms. 

Endocarditis  is  more  common  tlian  pericarditis.  It  may 
be  either  simple  or  malignant ;  it  occurs  as  an  acute  exacer- 
bation not  infrequently  in  those  who  have  old  valvular 
disease. 

Meningitis  may  occur,  and  it  is  usually  associated  with 
malignant  endocarditis.  It  is  often  difficult  to  tell  whether 
pneumonia  or  meningitis  be  the  primary  disease.  Croupous 
gastritis  or  colitis  may  occur.  The  liver  and  the  kidney 
usually  show  parenchymatous  changes. 

Symptoms. — Prodromal  symptoms,  consisting  of  malaise, 
dull  pain  in  the  back  and  the  bones,  and  some  soreness  in 
the    chest,   are    present   in   about   one-fourth   of  the   cases. 


Day  of 
Disease 

5 

6 

7 

8 

9 

10 

11 

12 

...  1 
1 

105° 
104° 

:l  : 
:i  : 

; 

A 

; 

103° 
102° 

V 

^ 

^ 

I  • 

K 

V 

\ 

A 

101° 
100° 
99° 

: 

^ 

> 

\ 

: 
• 

■ 

:1 

\> 

^ 

vj/ 

\ 

: 

i 

V 

:i  : 

98° 

. 

. 

■  1  ■ 

•    ■ 

•  i  • 

•1  '■ 

Fig.  27. — Temperature  chart  of  pneumonia  terminating  by  lysis. 

They  last  for  a  day  or  so,  and  probably  are  due  to  a  pro- 
tracted stage  of  congestion. 

The  actual  onset  of  the  disease  is  marked  by  one  or  more 
cliills  in  about  90  per  cent,  of  the  cases,  and  from  the  chill 
the  duration  of  the  disease  is  reckoned.  In  children  convul- 
sions or  vomiting  may  replace  the  chill.  In  old  people  a 
shivering  attack  and  pain  in  the  side  may  be  the  only 
symptoms. 

The  temperaUirc  rises  rapidly  and  attains  its  maximum  in 


298 


MAXi'AL    OF  THE   PRACTICE    OF  MEDICINE. 


from  twenty-four  to  thirty-six  hours,  although  in  some  cases 
the  height  of  the  fever  is  not  reached  until  the  da\'  before 
defervescence.  The  fe\'er  remains  high  with  slight  evening 
exacerbations,  which  in  uncomplicated  cases  should  not  ex- 
ceed 104°  F. 

Dcfcii'csccncc  may  occur  at  an\'  time  between  the  second 
and  the  eighteenth  day,  the  seventh,  fifth,  eighth,  sixth,  and 
ninth  davs  being  the  favorites,  in  the  order  named.    The  tern- 


Day  of 
Disease 

3 

4 

5 

0 

7 

8 

9 

10 

1 

106'^ 

: 

/ 

im. 

105= 
104*^ 

:• 

^■.\ 

'/^ 

/" 

i 

\v''' 

/ 

^ 

V' 

'^y 

^cl 

h 

V- 

■J    . 

\ 

103° 

: 

v 

V 

'■ 

r 

: 

Fig.  28. — Temperature  chart  of  pneumonia  with  purulent  inflammation  terminating  fatally. 

perature  ma\'  fall  in  from  six  to  forty-eight  hours  by  crisis, 
or  in  from  three  to  five  days  by  lysis.  In  some  cases  the 
temperature  is  markedly  remittent  at  any  time  in  its  course, 
especially  in  children.  In  other  cases  a  pseudo-crisis  occurs 
about  the  fifth  day.  At  the  time  of  the  crisis  the  tempera- 
ture may  fall  to  subnormal,  and  after  the  crisis  a  slight  rise 


Fig.  29. — Lobar  pneumonia  in  child,  with  remittent  temperature  (Holt). 

of  fever  is  noticeable  for  two  or  three  days,  especially  in 
the  evening.  A  high  temperature  persisting  for  ten  days 
suggests  purulent  infiltration  or  empyema.     A  sudden  rise 


LOBAR   PNEUMONIA. 


299 


of  temperature  at  any  time  indicates  a  complication  or  an 
extension  of  the  disease.  In  old  people  the  temperature 
may  be  normal  or  even  subnormal.  In  the  pneumonias 
complicating  epidemic  influenza  the  temperature  does  not 
become  normal  for  days,  and  it  may  even  persist  after  reso- 
lution. 

The  character  of  tJie  heart's  action  is  of  the  utmost  import- 
ance, as  heart  failure  constitutes  th-e  greatest  danger  of 
pneumonia.  The  pulse  should  be  full  and  about  lOO  in  a 
favorable  case.  A  pulse  over  120  passes  the  safety  limit  and 
gives  cause  for  anxiety.  The  most  critical  time  is  just 
before  defervescence,  at  which  time  liability  to  sudden  or 
gradual  heart  failure  is  the  greatest.  The  possibility  of 
sudden  death  must  always  be  considered. 


Day  of 

Disease 

4 

6 

6 

7 

8 

9 

10 

11 

12 

105° 

104° 

; 

.;/ 

\: 

/ 

V 

/"k     • 

^ 

: 

f 

:/ 

103° 

■J 

t; 

'■ 

V 

y 

\ 

^ 

1 

V 

102° 

:\ 

S: 

; 

V 

/; 

DI 

!I). 

101° 

; 

\ 

/ 

>* 

\ 

'■■ 

Fig. 

30- 

-L 

Obc 

I-p 

nei 

imc 

nia; 

defe 

rve 

see 

nee 

:  i 

an 

jre 

le  ( 

3f  lur 

g- 

In  old  people  rigidity  of  the  arterial  walls  may  give  a 
fictitious  tension  to  the  pulse,  and  it  is  best  to  note  the 
character  of  the  action  of  the  heart  itself  Of  equal  import- 
ance with  a  rapid  pulse  in  old  people  is  an  irregular  and 
intermittent  heart-action. 

A  fall  in  the  pulse  even  to  50  may  be  noticed  before 
crisis.  In  case  of  rapid  defervescence  there  may  be  extreme 
prostration  and  heart  failure.  A  pulse  running  up  rapidly 
to  140  indicates  paresis  of  the  medulla  and  often  precedes 
the  fatal  issue.  In  children,  however,  a  rapid  pulse  is  not 
of  so  much  importance,  recovery  being  possible  even  with 
a  pulse  of  150  to  200. 


300        .UAXC'AL    OF   THE   PKACTICE    OF  MEDICINE. 

The  breathing  is  rapid  and  oppressed.  Its  rapidity  varies 
with  the  amount  of  fever,  tlie  extent  of  lunLj  involved,  the 
severity  of  pleuritic  pain,  and  the  presence  of  complications. 
The  respirations  should  be  below  40  to  the  minute,  a  tem- 
perature of  104°  F.,  respiration  of  40,  and  a  pulse  of  1 20 
being  the  safety  limits.  If  the  respirations  be  over  this 
limit,  there  should  be  suspicion  of  pleuritic  effusion  or 
pulmonary  oedema. 

Dysptuva  may  be  marked  in  some  cases,  especial]}-  in 
upper-lobe  pneumonias.  It  is  not  usually  noticed  in 
old  people,  in  whom  the  respiration  may  not  even  be  in- 
creased. 

Fain  in  the  chest,  usually  referred  to  the  nipple,  occurs  in 
85  per  cent,  of  all  cases.  It  is  a  true  pleuritic  pain,  and  it 
does  not  occur  unless  the  pleura  is  inflamed.  It  is  a  fairly 
constant  symptom  in  old  people. 

Congit  usually  comes  early  in  the  disease,  but  it  may  be 
deferred  until  after  defervescence,  or  it  may  be  absent  alto- 
gether, especially  in  old  people. 

The  spnUmi  is  scanty,  gelatinous,  and  rusty  in  color,  the 
little  pellets  sticking  to  the  side  of  the  cup ;  it  is  usually 
mixed  with  the  ordinary  sputum  of  bronchitis.  This  "  rusty 
sputum  "  is  very  characteristic.  At  the  onset  there  may  be 
expectorated  a  little  pure  blood.  In  bad  cases  there  may 
be  the  "prune-juice"  expectoration  of  an  abundant  dark- 
brown  fluid.  This  sign  is  a  serious  one.  In  some  cases  the 
patient  will  raise  casts  of  the  small  bronchi  that  unroll  in 
water.  In  children  the  sputum  is  usually  swallowed  instead 
of  being  expectorated. 

Cerebral  Symptoms. — Headache,  restlessness,  and  sleep- 
lessness are  frequent ;  they  appear  to  be  due  to  the  pyrexia. 
Delirium  belongs  to  the  severe  forms  of  the  disease  ;  it  is  said 
to  be  more  common  in  apex  pneumonia.  In  some  cases  it 
depends  upon  the  pyrexia  and  is  marked  by  mental  wander- 
ing, especially  at  night.  In  debilitated  subjects  and  in  very 
severe  cases  the  symptoms  of  the  "  typhoid  state  "  appear — 
rapid  feeble  pulse,  great  prostration,  brown  dry  tongue,  and 
a  muttering  delirium.  The  last-named  symptom  is  com- 
monly seen   in  alcoholic  subjects,  who  are,  moreover,  liable 


LOBAR   J'NEUMON/A.  3OI 

to  develop  the  typical  symptoms  of  acute  delirium  tremens. 
Old  people  arc  apt  to  wander  in  the  mind  and  to  evince  a 
constant  desire  to  leave  their  bed  and  walk  about;  as  a  rule, 
however,  they  are  readily  controlled.  In  some  non-alcoholic 
adults  there  maybe  acute  mania.  In  children  cerebral  symp- 
toms are  more  constant,  often  presenting  the  clinical  picture 
of  acute  meningitis.  Convulsions  at  the  onset  may  be  fol- 
lowed by  headache,  photophobia,  boring  of  the  head  into  the 
pillow,  convulsive  movements,  and  coma. 

Digestive  symptoms  are  usually  not  marked.  There  may 
be  nausea  and  vomiting,  especially  in  alcoholic  subjects,  and 
in  some  cases  a  catarrhal  jaundice  appears.  The  bowels  are 
usually  constipated  ;  the  tongue  is  coated.  A  brown  dry 
tongue  belongs  to  the  most  severe  cases. 

The  tirinc  is  that  of  fever,  concentrated  and  depositing 
urates.  There  is  usually  a  diminished  amount  of  sodium 
chloride,  but  this  sign  is  not  diagnostic.  In  about  one-third 
of  the  cases  albumin  and  casts  are  present  from  a  complicat- 
ing parenchymatous  nephritis,  which,  however,  gives  no 
symptoms.  It  is  important  to  examine  the  urine  in  every 
case,  to  determine  the  presence  of  chronic  Bright's  disease, 
which  adds  so  grave  an  element. 

The  appearance  of  the  patient  is  often  characteristic.  The 
decubitus  is  usually  on  the  affected  side.  The  expression 
is  both  apathetic  and  anxious.  There  is  frequently  a  well- 
defined  mahogany-colored  flush  on  one  or  on  both  cheeks 
— not  always  limited,  as  was  once  supposed,  to  the  affected 
side.  Herpes  labialis  occurs  in  a  certain  number  of  cases  : 
this  sign  is  to  be  regarded  as  a  favorable  one.  The  herpetic 
vesicles  frequently  contain  the  pneumococci. 

The  physical  signs  may  be  described  as  those  occurring 
(i)  in  the  stage  of  congestion,  (2)  in  the  stage  of  consolida- 
tion, and  (3)  in  the  stage  of  resolution. 

I.  Stage  of  Congestio)i. — The  normal  ph\-sical  signs  are 
the  crepitant  rale,  the  subcrepitant  rale,  a  slight  dulness, 
and  a  localized  deficienc\-  in  chest-expansion.  The  crepi- 
tant rale  consists  of  a  shower  of  fine  dry  crackles,  heard 
directly  under  the  ear  at  the  end  of  inspiration  only.  This 
rale  was  formerly  considered  pathognomonic  of  pneumonia, 


and  to  be  due  to  the  inspiratory  stretching  of  the  alveolar 
walls  stiffened  by  inllamniatory  infiltration.  It  is  now  con- 
sidered to  be  a  pure  and  simple  pleural  rale,  and  is  con- 
sequently present  only  when  the  pleura  is  inllanied.  The 
subcrepitant  rale  may  arise  either  from  the  rubbing  together 
of  the  inflamed  pleurze  or  from  exudate  in  the  small  bronchi. 
Slight  dulness  is  apparent  by  a  percussion-note  of  shorter 
duration,  higher  pitch,  and  less  resonance  than  normal. 
Deficiency  in  chest-expansion  is  best  appreciated  by  pal- 
pation. 


Fig.  31. — Physical  signs  of  lobar  pneu- 
monia during  the  stage  of  congestion : 
slight  dulness  or  dull  tympany;  breath- 
ing feeble  or  harsh;  crepitant  and  sub- 
crepitant pleuritic  rales. 


Fig.  32. — Physical  signs  of  lobar  pneu- 
monia during  the  stage  of  complete  con- 
solidation :  dulness ;  bronchial  voice  and 
breathing;  increased  vocal  fremitus;  crep- 
itant and  subcrepitant  pleuritic  rales. 


Exceptional  Signs. — There  may  be  a  general  bronchitis 
with  bronchial  rales  obscuring  the  physical  signs.  In  these 
cases  the  disease  may  be  mistaken  for  bronchitis  or  for 
tubercular  disease.  There  may  be  only  an  area  of  feeble  or 
harsh  breathing,  with  an  occasional  subcrepitant  rale.  In- 
stead of  slight  dulness  there  may  be  a  tympanitic  note  due 
to  relaxation  of  the  congested  alveolar  walls,  or  a  note  of 
mixed  tympany  and  dulness.  Should  the  lesion  begin  in 
the  deeper  parts  of  the  lung,  physical  signs  may  be  absent 
entirely.  If  the  pleura  be  not  involved,  the  crepitant  rale  is 
not  present. 

2.  Stage  of  Co7isolidation. — The  normal  signs  are  dul- 
ness, increased  vocal  fremitus,  bronchial  voice  and  breath- 
ing, crepitant  and  subcrepitant  rales,  and  diminished  chest- 
expansion,      Dulness    is   shown    by  a  short,   high-pitched 


LOBAR   PNFJJMONfA.  3O3 

note  of  feeble  resonant  quality,  with  an  appreciable  lack 
of  resiliency  to  the  percussing  finger.  Bronchial  breath- 
ing consists  of  a  harsh,  loud,  and  high-pitched  respira- 
tory murmur,  in  which  the  sound  produced  by  expiration 
is  higher  pitched  and  more  prolonged  than  that  of  in- 
spiration. Bronchial  voice  is  high-pitched,  loud,  and 
nasal    in    quality. 

Exceptional  Signs. — The  dulness  may  have  a  decided 
tympanitic  quality,  resembling  in  some  cases  even  the 
"  cracked-pot  "  or  the  amphoric  note.  These  modifications 
are  more  commonly  observed  in  pneumonia  of  the  apex ; 
they  are  especially  marked  in  children.  In  some  cases 
the  note  may  be  flat,  especially  if  the  bronchi  be  filled 
with  exudate,  but  the  flatness  is  never  so  complete  as  in 
pleural  effusion.  Should  the  pneumonic  area  be  small, 
dulness  may  be  obscured  by  the  tympanitic  note  pro- 
duced in  the  surrounding  lung-tissue  by  its  congestion 
and  relaxation. 

Bronchial  voice  and  breathing  may  be  absent  They 
depend  upon  the  flow  of  air  in  the  bronchi,  and  they  are 
absent  if  the  bronchi  are  occluded  or  if  the  lung  does  not 
expand  with  respiration ;  hence  they  may  be  brought  out 
by  coughing  or  by  deep  breathing. 

The  crepitant  rale  may  be  absent,  either  because  the 
pleura  is  not  involved  or  because  of  the  poor  expansion  of 
the  lung.  Vocal  fremitus  rarely  is  diminished  or  absent 
If  the  consolidation  begin  in  the  deeper  parts  of  the  lung— 
the  so-called  "  central  pneumonia " — the  physical  signs 
may  be  delayed  for  several  days,  making  the  diagnosis  often 
extremely  difficult 

In  old  people,  in  whom  respiration  is  feeble,  the  only 
physical  signs  may  be  the  subcrepitant  rale  and  the  feeble 
breathing.  Dulness  is  frequently  absent  in  the  aged,  in 
Avhom  senile  changes  in  the  ribs  allow  of  increased  res- 
onance on  percussion. 

3.  Stage  of  Resolution. — The  dulness  becomes  less  and  less 
marked,  bronchial  voice  and  breathing  become  broncho- 
vesicular  and  finally  normal,  vocal  fremitus  diminishes  to 
the  normal  limit,  and  moist  bronchial  rales  appear. 


304        .)/.l.\(.ll    Vl-    Till-:    PKACI'JCl:    OF  MEDICJXK. 


Fig.  33. —  Physical  signs  of 
lobar  pneumonia  during  the 
stage  of  resolution  :  dull  tym- 
pany or  tympany ;  broncho- 
vesicular  voice  and  breathing, 
becoming  harsh,  feeble,  or 
normal ;  vocal  fremitus,  be- 
coming normal;  crepitant 
and  subcrepitant  pleuritic 
rales;  moist  bronchial  rales. 


lixct'piioual  Signs. — The  dulness  may  change  to  tympany, 
which  is  often  the  earhest  sign  of  resolution.  Crepitant  and 
subcrepitant  rales,  if  formerly  absent, 
may  be  heard,  from  increased  lung-ex- 
pansion. In  some  cases  the  moist  bron- 
chial rales  are  not  present.  Should 
thickening  t)f  the  [jjeura  persist,  slight 
ilulness,  feeble  breathing,  and  the  crepi- 
tant rale  may  be  present  for  a  consider- 
able time. 

Complications. — Pleurisy  with  effu- 
sion is  to  be  suspected  should  there  be 
disproportional  rapidity  of  breathing, 
and  a  continuance  of  fever  beyond  the 
natural  duration  of  pneumonia.  Empy- 
ema is  marked  by  the  occurrence  of 
septic  symptoms,  erratic  chills,  irregular 
temperature  curve,  and  sweating.  The 
ph)'sical  signs  are  those  of  fluid  in  the 
pleural  cavity,  but  bronchial  voice  and 
breathing  may  be  heard  below  the  level  of  the  fluid.  In  doubt- 
ful cases  an  exploratory  aspiration  should  be  resorted  to. 

Abscess  of  the  lung  occurs  in  about  i  per  cent,  of  cases, 
from  added  infection  by  suppurative  microbes.  It  is  usually 
seen  in  debilitated  subjects.  Septic  symptoms  are  present. 
There  is  an  expectoration  of  pus,  often  fetid,  containing 
shreds  of  lung-tissue,  and  prostration  is  extreme.  In  old 
people  there  may  be  no  marked  symptoms. 

The  physical  signs  are  those  of  pulmonary  cavities — 
tympanitic  or  "  cracked-pot "  note,  cavernous  voice  and 
breathing,  with  moist  and  guigling  rales.  These  signs  are 
often  present  over  a  consolidated  lung-area  containing  a 
large  bronchus  with  adherent  pleural  surfaces,  so  that  a 
diagnosis  by  physical  signs  alone  is  often  impossible. 
Many  so-called  cases  of  "  abscess  of  the  lung  "  compli- 
cating pneumonia  are  really  acute  phthisis  with  the  rapid 
formation  of  cavities.  In  doubtful  cases  a  bacterial  exam- 
ination of  the  sputum  for  the  tubercle  bacillus  should  be 
made. 


f.OBAR    PNEUMONIA.  305 

Gangrene  of  the  lung  is  somewhat  less  common  than 
abscess.  The  expectoration  is  a  <^reenish  or  brownish  fluid, 
of  fetid  ijangrenous  odor,  contain ini:^  shreds  of  decomposed 
lung-tissue  and  crystals  of  fatty  acids.  Constitutional  symp- 
toms are  usually  pronounced. 

Pericarditis  in  some  cases  adds  typical  sjmiptoms — dysp- 
noea, rapid  and  feeble  pulse,  venous  congestions,  and  char- 
acteristic physical  signs.  In  other  cases  the  diagnosis  is 
less  evident.  Pericardial  rales  may  be  simulated  by  the 
rubbing  together  of  overlying  inflamed  pleural  surfaces  at 
each  systole  of  the  heart,  and  signs  of  fluid  maybe  obscured 
should  the  pneumonia  involve  the  overlying  portion  of  the 
lung. 

Endocarditis  may  be  either  simple  or  malignant.  The 
latter  is  to  be  suspected  should  septic  and  embolic  symp- 
toms be  present.  Pneumonia  occurring  in  a  patient  the 
victim  of  chronic  endocarditis  may  upset  compensation  and 
lead  to  heart  failure.  During  the  pneumonia  pre-existing, 
murmurs  of  valvular  disease  may  be  absent  entirely. 

Meningitis  may  complicate  pneumonia  with  especial 
frequency  at  different  times  and  in  different  places.  It  may 
run  its  course  with  or  without  typical  symptoms.  This 
complication  may  be  mistaken  for  epidemic  cerebro-spinal 
meningitis  with  complicating  pneumonia,  for  tubercular 
meningitis  with  lesions  in  the  lungs,  and  for  uncomplicated 
pneumonia  in  children  with  marked  cerebral  symptoms. 

Puhnonary  o;devia  usually  ushers  in  the  fatal  issue.  The 
heart  failing,  the  right  ventricle  becomes  more  and  more 
distended,  with  consequent  congestion  and  oedema  of  the 
lungs.  The  pulse  becomes  rapid  and  feeble  ;  respirations 
are  shallow,  rapid,  and  attended  by  noisy  bubbling  sounds. 
The  expectoration  becomes  profuse  and  frothy,  and  it  may 
be  blood-stained.  Signs  of  deficient  aeration  of  blood 
appear,  and  consciousness  is  lost  some  few  hours  before 
death. 

Sudden  lie  art  faUure  ma}-  occur  at  any  time,  even  after 
defervescence.     The  most  usual  time  is  about  the  time  of 
crisis.     In  some  cases  thrombosis  of  the  coronary  or  of  the 
20 


306         A/.iXLAL    (.>/■•    riJE    PKACriCE    OF  MEDICfXE. 

pulmonary  artery  may  be  found  ;  in  other  cases  there  seems 
to  be  no  assignable  cause. 

C/iivjiic  interstitial  pneumonia,  or  fibroid  induration,  may 
in  rare  cases  result  from  the  organization  of  the  inflamma- 
tory exudate  into  connective  tissue,  rendering  the  affected 
area  of  lung  permanently  consolidated. 

Prog-nosis. — The  average  mortality  in  hospital  cases 
ranges  about  25  per  cent. ;  it  is  somewhat  less  in  private 
practice.  Pneumonia  of  the  apex,  an  extensive  lesion,  and 
old  age  render  the  outlook  serious,  and  the  complications 
increase  the  mortality  to  a  considerable  degree.  Alcoholism 
must  be  considered  in  making  the  prognosis.  According  to 
the  New  York  Hospital  records,  the  mortalit)'  in  non-alco- 
holic cases  was  25  per  cent. ;  in  slightly  alcoholic  subjects, 
33  per  cent. ;  in  those  with  a  marked  alcoholic  history,  72 
per  cent.  Patients  subject  to  chronic  Bright's  disease  are 
apt  to  die,  especially  if  they  be  addicted  to  alcohol.  At 
.the  New  York  Hospital  4  such  patients  recovered  and  36 
died.  The  earlier  the  patient  is  put  to  bed,  the  better  is  the 
prognosis. 

Treatment. — Pneumonia  is  a  self-limited  disease  and 
has  no  specific  medication.  In  many  cases  no  medicines  at 
all  are  required.  The  patient  should  be  kept  in  bed  until 
at  least  five  days  after  the  temperature  has  become  normal, 
and  on  a  liquid  or  light  diet.  Restlessness  and  sleepless- 
ness may^  be  controlled  by  phenacetine,  sulphonal,  chloral- 
amide,  or  by  a  Dover's  powder  given  at  night.  Pain  in  the 
side  may  be  relieved  by  hot  poultices  or  by  a  hypodermic 
injection  of  morphine.  Poultices  need  not  be  applied,  how- 
ever, as  a  routine  measure;  in  fact,  many  patients  are  more 
relieved  by  cold  applications  to  the  chest  by  ice-bag.s — a 
treatment  which  appears  to  exert  a  beneficial  effect  upon 
the  disease  itself 

All  attempts  to  abort  the  disease  have  proved  futile. 
Large  doses  of  calomel — from  25  to  40  grains  placed  dry 
on  the  tongue — seem  to  exert  a  beneficial  effect  upon  the 
course  of  the  disease  in  some  cases,  producing  a  sedative 
effect,  but  there  is  always  the  risk  of  producing  salivation. 
Venesection    at    the    outset    in    robust    subjects   with   pro- 


LOBAR   PNEUMONIA.  ^OJ 

nounced  inflammatory  symptoms  is  often  of  the  greatest 
service,  relieving  the  dyspncEa  and  the  cerebral  symptoms 
and  reducing  the  fever.  In  the  later  stages,  when  the  heart 
is  beginning  to  fail,  and  cyanosis  and  symptoms  of  dilata- 
tion of  the  right  ventricle  appear,  venesection  may  be  em- 
ployed as  a  last  resort. 

As  an  arterial  sedative  tincture  of  aconite  or  tincture  of 
veratrum  viride  has  seemed  to  be  of  service  if  given  at  the 
outset,  but  in  robust  patients  venesection  is  preferable. 

The  temperature,  being  of  relatively  short  duration,  rarely 
requires  much  treatment.  The  use  of  internal  antipyretics 
as  a  routine  is  to  be  deplored,  on  account  of  their  depressant 
effect.  High  and  prolonged  temperature  should,  however, 
be  controlled.  For  this  purpose  hydrotherapy  is  the  best 
treatment  to  be  employed — either  cold  sponging,  the  cold 
pack,  cold  applications  to  the  chest,  or  even  the  bath  at  70° 
F.  By  the  use  of  the  bath  the  temperature  is  reduced,  the 
pulse  becomes  stronger,  and  cerebral  symptoms  are  markedly 
relieved. 

By  far  the  most  important  treatment  is  that  to  sustain  the 
action  of  the  heart.  Should  the  pulse  become  rapid  and 
feeble  and  the  second  pulmonary  sound  weak,  alcohol 
should  be  given  freely,  in  doses  sufficient  to  accomplish 
the  end  desired.  In  the  aged  and  in  alcoholic  subjects  it 
should  be  given  from  the  start.  The  use  of  digitalis  is 
frequently  disappointing  from  its  contractile  power  over 
the  small  arteries,  unless  it  be  combined  with  an  arterial 
relaxant,  such  as  nitroglycerin  or  iodide  of  potassium.  A 
good  combination  is — 

I^.    Potassii  iodidi,  gr.  v; 

Ext.  digitalis  fluid.,  TTLj ; 

Ext.  convallariae  fluid.,    TTlxx. — M. 
Sig.    Such  a  dose  every  three  hours. 

As  a  cardiac  tonic  strychnine  is  rapidly  gaining  in  favor. 
It  may  be  combined  with  digitalis  and  aconitine  with  advan- 
tage, as  in  the  following  prescription  : 


308        M.LVC.iL    OF    TJ/J-:   PRACTICE    OF  MFD/CIXE. 

R.    Strychnine  sulphate.       Sjr.  ^v'^^ ; 
Digitahne,  g'- t^  ; 

Aconitine.  t;r.  y-^. 

Such  a  combination  in  pill  form  ma\-  be  t^iven  ever}'  two  or 
three  hours  until  the  pulse  is  reduced  to  about  lOO,  but 
with  such  a  form  of  treatment  the  patient  should  be  watched 
carefully.     Ammonia  or  camphor  may  also  be  employed. 

Should  heart  failure  with  increasing  difficulty  of  breathing 
occur,  free  stimulation,  cupping  of  the  chest,  and  the  admin- 
istration of  pure  oxygen  gas  should  be  employed  ;  in  .some 
cases  free  venesection  proves  satisfactory. 

Complicating  delirium  tremens  calls  for  free  stimulation, 
for  sedatives  such  as  bromide,  chloral,  or  hypodermic  injec- 
tions of  morphine,  and  frequently  for  plu'sical  restraint. 
The  sedative  and  tonic  effect  of  the  cold  bath  is  often  sur- 
prising in  these  cases. 

Expectorants  serve  only  to  upset  the  stomach,  although 
in  some  cases  of  tardy  resolution  pilocarpine  may  be  em- 
ployed, its  depressant  effect  being  carefully  guarded  by 
stimulants. 

Experiments  recently  made  by  Drs.  G.  and  F.  Klemperer 
upon  the  toxines  of  pneumonia  are  of  wonderful  and  vital 
interest.  These  observers  found  that  rabbits  could  be 
rendered  immune  by  hypodermic  injections  of  heated  pneu- 
mococcus  cultures,  and  that  the  blood-serum  from  these 
rabbits,  injected  into  patients  suffering  from  pneumonia, 
produced  an  immediate  curative  effect  upon  the  disease. 
More  recently  the  blood-serum  of  patients  who  had  just 
passed  the  time  of  crisis  has  been  used  for  the  injections, 
with  equally  brilliant  results,  the  theory  being  that  the  serum 
from  immune  animals  or  from  convalescent  patients  contains 
an  antitoxine  capable  of  neutralizing  the  toxine  caused  by 
the  growth  of  the  pneumococcus  in  the  bod}'.  The  latter, 
known  as  "  pneumotoxine,"  has  already  been  isolated,  but 
the  supposed  antidotal  toxine,  the  "  antipneumotoxine,"  has 
not  as  yet  been  obtained  in  a  chemically  pure  state. 


BN  ONCIJO-  PNE  UMONfA .  309 

BRONCHO-PNEUMONIA. 

Bitology  and  Synonyms. —  Hroncho-pncunionia  is  the 
regular  pneumonia  of  young  children,  but  it  may  be  .seen 
in  adults,  and  it  is  not  uncommon  in  old  people.  Primary 
cases  follow  exposure  to  wet  and  cold  or  the  inhalation  of 
irritating  chemical  vapors  ;  they  are  more  common  in  the 
winter  and  spring  months  and  among  the  debilitated  tene- 
ment-house and  asylum  children.  Secondary  cases  accom- 
pany many  of  the  infectious  diseases,  especially  measles, 
scarlet  fever,  whooping-cough,  and  diphtheria.  Broncho- 
pneumonia may  occur  in  any  disease  which  keeps  the 
patient  in  bed,  the  dorsal  decubitus  preventing  free  expec- 
toration, and  the  foul  mouth  of  fevers  allowing  the  growth 
of  bacteria  in  the  mouth.  The  bacteria  enter  the  lung 
with  the  inspired  air  and  infect  it.  Careful  cleansing  of  the 
mouth  in  prolonged  fevers  will  often  prevent  the  occurrence 
of  this  so-called  "  aspiration-  "  or  "  inhalation-pneumonia." 
"  Deglutition-pneumonia  "  is  that  form  of  pneumonia  pro- 
duced by  the  passage  of  food  or  drink  into  the  bronchi 
from  choking  at  table,  in  deep  coma,  or  from  tracheotomy, 
intubation,  or  cancer  of  the  larynx  or  the  oesophagus. 
Suppuration  or  even  gangrene  may  result  in  such  cases. 
Patients  with  advanced  emphysema  are  liable  to  subacute 
attacks  of  broncho-pneumonia.  Tubercular  broncho-pneu- 
monia will  be  considered  under  a  separate  heading.  Bron- 
cho-pneumonia may  be  produced  either  by  the  ordinary 
pneumococcus  or  by  the  streptococcus  of  suppuration. 
Synonyms:  Lobular  pneumonia;  Catarrhal  pneumonia; 
Capillary  bronchitis. 

Pathology. — The  lesion  consists  of  a  bronchitis  and  a 
pneumonia.  The  broncldtis  is  general,  involving  the  bronchi 
of  both  lungs.  The  large,  the  medium,  and  the  smallest 
bronchi  are  all  involved,  although  not  always  to  the  same 
extent.  The  mucous  membrane  of  the  bronchi  show  ordi- 
nary catarrhal  inflammation ;  the  walls  of  the  smallest 
bronchi  are  thickened  by  an  infiltration  of  new  cells,  and 
may  be  dilated  ;  the  smaller  bronchi  may  contain  pus.  The 
pneumonia   differs   from   lobar  pneumonia   in    the   location 


3IO        .U.LVC.IL    OF   THE   PRACTICE    OF  MEDICLXE. 

of  the  affected  areas  and  in  the  regular  involvement  of  the 
connective-tissue  walls  of  the  air-cells.  Around  the  bronchi 
are  zones  of  consolidated  lung-tissue,  varying  in  size  from 
a  pin's  head  to  that  of  a  pea.  These  areas  of  peri-bron- 
chitic  hepatization  may  be  so  slight  as  almost  to  escape 
notice,  so  that  the  lesion  appears  to  be  bronchitis  alone. 
These  cases  were  formerly  described  as  "  capillary  bron- 
chitis." In  other  cases  the  areas  are  larger,  so  that  the 
lungs  are  filled  by  these  isolated  nodular  bodies  ;  while  in 
yet  other  cases,  the  "  pseudo-lobar  form,"  the  areas  are  large 
and  confluent,  so  that  the  greater  part  of  the  lobe  is 
rendered  solid.  The  cut  surface  of  a  broncho-pneumonic 
patch  is  smooth,  lacking  the  granular  appearance  of  the 
hepatization  of  lobar  pneumonia.  Gray  hepatization  is  but 
rarely  seen. 

Microscopic  examination  shows  the  air-spaces  filled  with 
fibrin,  pus,  epithelial  cells,  and  red  blood-cells. 

In  children  there  is  a  relatively  greater  proportion  of 
epithelial  cells  in  the  exudate  than  in  adults.  The  walls 
of  the  air-spaces  are  thickened  and  are  infiltrated  by  small 
round  cells  or  by  fibrin,  pus,  and  epithelium. 

The  lung-tissue  between  the  nodules  may  be  either  nor- 
mal or  congested  and  cedematous,  or  it  may  be  the  seat  of 
a  diffuse  pneumonia  in  which  the  air-spaces  are  partially 
filled  with  fibrin,  pus,  epithelial  cells,  and  red  blood-cells,  or 
the  air-spaces  may  be  collapsed.  These  areas  of  collapse  or 
atelectasis  are  depressed  below  the  surrounding  tissues  and 
are  of  a  bluish  or  blue-brown  color.  These  areas  may  be 
small  and  may  only  surround  the  peribronchitic  nodules,  or 
the  greater  part  of  a  lobe  may  be  involved.  In  recent 
cases  the  air-spaces  may  be  inflated  by  a  blow-pipe  inserted 
into  the  bronchus  leading  to  them. 

The  pleura  covering  the  peripheral  pneumonic  patches  is 
covered  with  fibrin.  The  bronchial  glands  are  almost 
always  swollen  and  inflamed.  This  condition  may  persist, 
rendering  the  glands  susceptible  to  an  added  tubercular 
infection,  from  which  systemic  infection  may  result.  Many 
cases  of  tuberculosis  in  asylums  follow  epidemics  of 
measles,  the  sequence  being  measles,  broncho-pneumonia, 


BR O NCI/0- PNE  UAIONIA.  3 1  I 

inflammation,  tubercular  infection  of  the  inflamed  bronchial 
glands,  general  miliary  tuberculosis. 

There  is  a  common  misapprehension  that  the  inflamma- 
tion extends  from  the  bronchi  into  the  air-spaces  which 
open  into  them.  In  point  of  fact,  it  is  the  air-spaces  sur- 
rounding the  axis  of  the  bronchi  that  are  involved.  If  hot 
knitting-needles  be  run  into  a  loaf  of  bread,  the  path  of 
each  needle  will  represent  a  bronchus,  while  the  charred 
bread  surrounding  its  track  will  represent  the  position  of 
the  peribronchitic  pneumonia. 

The  interstitial  inflammation  of  the  walls  of  the  bronchi 
and  the  air-spaces  is  a  special  feature  of  broncho-pneumonia. 
It  is  of  especial  importance  from  its  tendency  to  become 
chronic,  by  the  changing  of  the  infiltrating  cells  into  devel- 
oped connective  tissue. 

Symptoms. — In  young  babies  fever,  prostration,  and  rapid 
breathing  are  the  only  constant  symptoms.  There  may  be 
no  cough,  and  physical  signs  are  not  present.  The  disease 
runs  almost  regularly  a  fatal  course  within  a  few  days. 

Mild  cases  in  children  may  resemble  severe  ordinary 
bronchitis.  In  broncho-pneumonia  the  general  symptoms, 
however,  are  more  severe,  and  the  physical  signs  point 
to  an  involvement  of  smaller  bronchi  than  in  bronchitis 
alone.  A  temperature  of  102.5°  oi"  103°  F.  persisting 
for  three  days  gives  evidence  of  more  than  a  simple  bron- 
chitis. 

Severer  forms  in  cliildren  may  begin  gradually  or  abruptly 
— gradually  by  the  extension  of  a  simple  bronchitis,  or 
abruptly  by  convulsions  or  vomiting.  Should  the  pneu- 
monia be  secondary  to  some  well-marked  infectious  disease, 
the  onset  is  somewhat  obscured. 

When  the  disease  is  established  there  is  a  fever  which  is 
usually  remittent  in  character,  often  markedly  so.  There  is 
no  typical  curve,  as  in  lobar  pneumonia,  and  there  is  no  day 
of  crisis.  The  height  of  the  fever  is  often  proportional  to 
the  severity  of  the  attack,  but  some  patients  do  badly  whose 
temperature  ranges  between  99°  and  100°  F.  The  circum- 
stances under  which  these  low  temperatures  are  met  with  are 
early  infancy,  low  vitality,  and  great  prostration  with  little 


12 


.U.LVr.lL    OF   Till:    PRACTICE    OJ-    MED/C/iVE. 


reactionary  power.  The  pulse  becomes  rapid,  freiiiieiitly 
ranging  from  140  to  180  in  man)'  children.  Respirations 
may  be  as  high  as  50  to  80  to  the  minute,  and  they  are 
marked  b}'  inspirator}-  dilatation  of  the  al.'e  nasi.  There  i.s 
often  an  expiratory  moan  or  grunt.  There  may  be  audible 
bronchial  rales.  The  dyspnoea  may  make  it  difficult  for 
the  child  to  nur^e.  There  is  frequently  cough,  which  may 
be  painful.  The  sputum  is  that  of  bronchitis  ;  it  is  usually 
swallowed,  but  it  max-  be  vomited  up.  Rusty  sputum  is 
not  present.  In  older  children  the  sputa  max-  be  blood- 
streaked.  The  face  is  flushed,  the  skin  is  dry,  the  tongue  is 
coated ;  vomiting  is  frequent,  and  it  may  interfere  with  the 
proper  feeding  of  the  child..  There  may  be  restlessness, 
sleeplessness,  or  mild  delirium,  depending  on  the  fever  and 
the  disposition  of  the  child.  The  urine  may  contain  small 
amounts  of  albumin  and  casts.      In  cases  developing  during 


J05° 

1 

2 

3 

4 

r, 

6 

; 

8 

9 

10 

n 

12 

13 

14 

15 

16 

108" 
102' 
lOl" 
100° 

< 

K 

A 

/ 

1 

/ 

-»^ 

l\ 

^ 

s 

/ 

V 

A 

V 

/ 

\ 

\ 

^ 

\ 

\ 

\J 

y 

V 

V 

"^ 

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\ 



\ 

L 

/ 

L: 

Fig.  34  — 'rypi';al  broncho-pneumonia  of  the  milder  form  (Holti. 

some  severe  disease,  constitutional  symptoms  inay  be  ob- 
scured, the  rapid  breathing  alone  attracting  attention  to 
the  lung. 

Cei'ebral  Cases. — There  are  cases  in  which  the  cerebral 
symptoms  may  be  so  pronounced  as  to  obscure  those  of 
pulmonary  origin.  There  may  be  headache,  repeated  con- 
vulsions, delirium,  photophobia,  retraction  of  the  head,  and 
muscular  twitchings.  Pulmonary  symptoms  appear  later  in 
the  disease  in  the  majority  of  cases,  with  a  subsidence  of 
the  cerebral  symptoms.  The  diagnosis  from  meningitis  in 
many  cases  is  difficult.  The  points  in  favor  of  pneumonia 
are  absence  of  tuberculosis  or  of  suppurative  ear  disease,  a 
higher  respiration-rate,  absence  of  paralysis,  a  more  rapid 
pulse,  and  the  presence  of  physical  signs.  The  cerebral 
symptoms,    moreover,   are    neither   so   severe   nor   so   con- 


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3'3 


tinuous   as   in   meningitis,  and   they  disappear  with    defer- 
vescence. 

Physical  Signs. — In  all  cases  sii^iis  of  bronchitis  are 
present — coarse  and  subcrepitant  rales,  especially  at  the 
bases,  with  sibilant  and  sonorous  breathing.  If  the  pneu- 
monic patches  be  small  and  scattered,  there  may  be  no 
added  signs,  so  that  the  diagnosis  from  bronchitis  will  be 
made  by  other  raeans.  If  the  pneumonic  patches  be  larger 
and  nearer  one  another,  there  will  be  a  tympanitic  or  dull  note 
with  harsh  breathing.  If  the  patches  so  coalesce  as  to 
involve  a  larger  area,  there  will  be  dulness,  bronchial  voice 


Fig,  35. — Broncho-pneumonia  :  zones 
of  peribronchial  consolidation  very  slight  ; 
physical  signs  of  bronchitis  ("  capillary 
bronchitis  "). 


Fig.  36. — Broncho-pneumonia  :  zones  of 
peribronchial  consolidation  more  extensive; 
physical  signs  of  general  bronchitis  and 
of  small  localized  areas  of  consolidation. 


and  breathing,  and  increased  vocal  fremitus.  Fibrin  on  the 
pleura  gives  rise  to  crepitant  and  subcrepitant  rales  of  super- 
ficial quality. 

Course  and  Termination. — The  disease  may  terminate — 
(i)  In  resolution.  The  disease  continues  for  from  two  to 
three  weeks  in  the  majority  of  cases,  the  temperature  fall- 
ing by  lysis.  In  some  cases  the  symptoms  continue  for 
from  six  to  eight  weeks  before  recovery.  Resolution  is 
slower  than  in  lobar  pneumonia,  being  rarely  completed  in 
less  than  from  seven  to  fourteen  days. 

(2)  /;/   death  from   asphyxia.      In   cases   that  are   doing 


314        M.lXr.lL    OF   THE   PRACTICE    OF  MEDICINE. 


poorly  the  d\'spnoea  becomes  more  distressing,  the  skin  is 
bluish,  and  the  pulse  becomes  more  and  more  rapid  and 
feeble.  -  As  the  child  gradually  succumbs  to  carbon-dioxide 
poisoning  the  dyspnoea  becomes  less  apparent,  distress  gives 
way  to  stupor  alternating  with  restlessness,  the  cyanosis 
deepens,  the  bronchi  fill  with  mucus,  and  death  results  from 
heart  parah'sis. 

(3)  In  suppuration  or  gangrene.  Either  termination  is 
rare  except  in  the  aspiration  and  deglutition  forms. 

(4)  ///  chronie  interstitial  pneumonia.  In  these  cases  the 
cells  infiltrating  the  walls  of  the  bronchi  and  of  the  air-cells 
become  organized  into  connective  tissue.  In  this  way  the 
walls  of  the  bronchi  are  thickened  and  dilated  and  are  sur- 
rounded by  zones  of  connective  tissue  that  represent  the 
former  areas  of  peribronchitic  pneumonia.  By  the  coales- 
cence of  these  zones  more  or  less  of  the  lung  is  rendered 
permanently  unfit  for  use.  The  pulmonary  pleura  is  usually 
much  thickened.    Such  a  lung  is  exceedingly  apt  to  develop 

tubercular  changes  in  the  course  of 
time. 

In  some  cases  the  pneumonia 
runs  an  acute  course,  and  in  one  or 
two  weeks  the  temperature  falls  and 
the  child  becomes  better  but  cannot 
be  said  to  be  actually  conv^alescent. 
There  continues  to  be  a  moderate 
irregular  fever;  the  cough  contin- 
ues and  emaciation  becomes  more 
marked. 

After  a  few  months  some  of  these 
cases   recover,  though    with    small 
Fig.  37.-Broncho-pneumonia :   ^^^^^  of  intcrstitial  pneumouia  which 

peribronchial  consolidation  exten-  '■ 

sive,  giving  ihe  physical  signs  of  may    givc    uo    further    troublc     or 

consolidation   of   large   areas,    re-     ^^^j^j^  ^^^^^     repeated     attacks 

sembling  lobar  pneumonia.  ■'  " 

of  bronchitis,  while  in  other  chil- 
dren tuberculosis  develops,  either  from  infection  from  tuber- 
cular bronchial  glands  or  from  a  local  infection  of  the  dis- 
abled lungs  by  the  tubercle  bacillus. 

In  other  cases  the  fever,  cough,  and  emaciation  continue. 


BR  ONCIIO-PNE  UMON/A.  3  I  5 

hectic  develops,  and  the  child  dies  emaciated  and  exhausted. 
The  course  of  the  disease  is  that  of  chronic  pulmonary- 
phthisis,  but  at  the  autopsy  there  is  found  extensive  inter- 
stitial pneumonia  with  large  bronchiectatic  cavities. 

Broncho-Pneumonia  in  Adults. 

The  disease  in  adults  presents  a  variety  of  clinical  forms 
which  are  thus  described  by  Delafield  : 

1.  There  is  first  ordinary  bronchitis  for  several  days,  but, 
instead  of  recovering,  the  patient  continues  to  cough  and  to 
feel  sick,  and  at  some  part  of  the  chest  there  is  found  a 
small  area  of  dulness  and  high-pitched  voice.  The  consoli- 
dation lasts  but  a  short  time,  and  the  patient  regularly 
recovers. 

2.  The  patient  is  seized  by  a  chill ;  there  are  rapid  and 
high  fever,  pains  in  the  back  and  the  chest,  great  prostra- 
tion, rapid  and  feeble  pulse,  rapid  and  insufficient  breathing, 
cough  with  mucous  and  blood-stained  sputa,  sleeplessness, 
restlessness,  and  delirium.  The  urine  contains  albumin  and 
casts ;  the  skin  is  cyanosed ;  the  viscera  are  congested. 
Over  both  chests  the  percussion-note  is  normal,  exagger- 
ated, or  dull.  Coarse  subcrepitant  and  crepitant  rales  with 
sibilant  and  sonorous  breathing  are  heard.  The  disease 
lasts  for  one  or  two  weeks  and  is  apt  to  prove  fatal. 

3.  A  form  of  broncho-pneumonia  resembles  lobar  pneu- 
monia. There  is  a  general  bronchitis,  with  broncho-pneu- 
monia and  consolidation  of  one  or  more  lobes.  Compared 
with  lobar  pneumonia,  the  invasion  is  more  gradual,  the 
pulse  is  more  rapid,  cerebral  symptoms  are  more  constant, 
the  sputum  is  that  of  bronchitis,  the  physical  signs  are 
delayed  in  their  appearance,  the  duration  is  longer,  and 
resolution  is  slower. 

4.  A  form  resembles  tubercular  broncho-pneumonia. 
The  invasion  is  gradual  and  the  disease  is  protracted  for 
weeks.  The  patients  have  fever  with  evening  exacerbations 
and  night-sweats,  cough  with  muco-purulent  expectoration 
which  does  not  contain  tubercle  bacilli,  and  there  is  a  loss 
of  flesh  and  of  strength.  Physical  signs  show  bronchitis 
with  localized  areas   of  consolidation.     Some  patients   re- 


3l6        M. I. veil.    OF    17//:    /'R.IC/7CK    OF  .VFDICIXF. 

cover  after  a  iiunilxr  of  weeks  ;   in  others  the  disease  proves 
fatxil. 

5.  Patients  with  eiiiphyscMiia  nia\'  develop  a  subacute 
broncho-pneumonia  wliich  is  often  fatal. 

6.  Broncho-pneumonia,  especially  of  the  lower  lobes,  may 
be  seen  in  infectious  tliseases,  injuries,  and  operations  which 
cause  congestion  of  the  lungs  and  allow  of  the  inhalation  of 
streptococci. 

The  prognosis  depends — (i)  Upon  the  age.  The  disease 
is  generally  fatal  in  young  infants.  The  mortality  is  50  per 
cent,  under  one  year,  40  per  cent,  between  the  first  and  the 
third  year,  and  25  per  cent,  between  the  third  and  the  fifth 
year.  (2)  Upon  the  severity  of  the  attack.  Mild  cases  may 
be  no  more  fatal  than  bronchitis.  (3)  Upon  the  general  nutri- 
tion of  the  child,  being  worse  in  asylum-  and  tenement- 
house  cases.  (4)  Upon  the  nature  of  the  primary  disease, 
being  worse  with  whooping-cough,  measles,  or  diphtheria. 
Aspiration-  and  deglutition-pneumoniasare  usually  severe. 
An  absolute  prognosis  should  never  be  made,  as  the  sickest 
child  may  recover  and  apparently  mild  cases  may  do  badly. 

The  prognosis  in  cases  of  chronic  broncho-pneumonia 
depends  upon  the  amount  of  lung  disabled,  the  possibilit}' 
of  avoiding  tubercular  infection,  and  the  care  that  can  be 
taken  of  the  case. 

Treatment. — Much  can  be  done  to  prevent  the  disease. 
Convalescent  fever  patients,  and  especially  those  convales- 
cing after  measles  or  whooping-cough,  should  be  guarded 
carefully  from  catching  cold.  All  bronchial  affections  in 
young  children  and  in  the  debilitated  and  the  aged  should 
be  attended  to  properly,  especially  in  the  winter  and  spring 
months.  The  mouth  and  the  teeth  of  all  fever  and  bed- 
ridden patients  should  be  kept  scrupulously  clean  by  fre- 
quent washings  with  antiseptic  solutions.  H\-postatic  con- 
gestion is  to  be  prevented  by  occasional  change  of  position 
in  bed. 

In  general  terms,  the  treatment  of  broncho-pneumonia 
is  that  of  lobar  pneumonia,  except  that  the  patient  is 
usually  a  young  child  and  that  the  bronchitis  is  an  additional 
feature.     There  is,  moreov^er,  less  danger  of  heart  failure 


BR0NC/I0-rNEUMO\l.\.  3  [  / 

than  in  lobar  pneumonia.  The  patient  shtnild  be  put  to 
bed  in  a  room  having  a  temperature  of  about  68°  or  72°  F., 
the  air  being  kept  moist  by  a  steam-kettle  or  an  atomizer. 
The  diet  should  be  fluid  during  the  febrile  stage,  and  the 
patient  should  be  allowed  cool  wiiter  sufficient  to  quench 
the  thirst.  At  the  outset  the  bowels  should  be  opened, 
calomel  (gr.  -^  every  hour  until  an  movement  occurs)  being 
generally  advisable.  For  the  febrile  .symptoms  an  ordinary 
saline  fever-mixture  may  be  employed,  such  as  citrate  of 
potash,  liquor  ammonise  acctatis,  or  spiritus  aetheris  nitrosi. 
If  there  be  high  fever  with  bounding  pulse,  minim  dosc.s  of 
tincture  of  aconite  may  be  employed  every  i  to  3  hours. 
Internal  antipyretics  are  not  to  be  recommended.  Should 
the  fever  need  reduction,  it  is  best  to  emi)loy  the  cold  bath 
or  the  wet  pack,  beginning  with  a  tepid  temperature  and 
gradually  reducing  it  to  80°  or  75°  F. 

For  the  bronchitis  counter-irritation  may  be  applied  to  the 
chest  by  turpentine  and  sweet  oil,  by  mustard  poultices 
made  thin  and  light,  or  by  chloroform  liniment.  The  chest 
may  be  covered  with  the  oil-silk  jacket,  which  consists  of  a 
flannel  shirt  over  which  are  sewn  strips  of  oil  silk.  Poul- 
tices are  heavy  and  are  not  so  much  employed  now  as 
formerly.  Expectorants  are  to  be  given  in  the  majority  of 
cases,  as  in  simple  bronchitis,  but  disturbance  of  the  stomach 
and  continual  nausea  should  be  avoided.  If  the  child  has 
trouble  in  bringing  up  the  mucus,  an  occasional  emetic  is 
often  valuable,  provided  the  heart  be  acting  well. 

In  commencing  asphyxia  and  heart  failure  inhalations  of 
pure  oxygen  gas  are  to  be  recommended,  and  vigorous 
heart-stimulation  is  to  be  employed,  digitalis,  strychnine, 
and  small  doses  of  brandy  being  used  for  this  purpose.  Un- 
der these  circumstances  a  hot  mustard  bath  for  the  entire 
body  is  often  beneficial. 

Pain  and  distressing  cough  frequently  require  small  doses 
of  Dover's  powder  or  codeine,  but  opium  must  be  given 
with  extreme  caution  to  young  children. 

Cerebral  symptoms  are  best  treated  by  phenacetine,  so- 
dium bromide,  or  chloral,  and  by  the  cold  pack.  If  resolu- 
tion be  delayed  or  if  the  danger  of  a  persistent  interstitial 


31  8        M.IXC'AL    OF   THE   PRACTICE    OF  MEDICINE. 

pneumonia  threaten,  a  vigorous  tonic  treatment  of  iron, 
quinine,  and  cod-liver  oil  is  to  be  employed,  with  strict 
attention  to  the  diet  and  the  assimilation  of  food.  Should 
these  means  prove  inoperative,  a  change  of  air  is  advisable. 

INTERSTITIAL    PNEUMONIA. 

Definition. — Interstitial  pneumonia  is  a  chronic  inflam- 
mation of  the  connective-tissue  framework  of  the  lung, 
resulting  in  the  production  of  new  connective  tissue  and  the 
obliteration  of  the  air-spaces. 

Etiology. — The  disease  is  part  of  the  lesion  of  chronic 
pulmonary  phthisis,  of  syphilitic  pneumonia,  and  of  sub- 
stantive emphysema.  It  occurs  as  the  result  of  chronic 
bronchitis,  pleuritic  adhesions,  broncho-pneumonia,  lobar 
pneumonia,  and  the  continual  inhalation  of  solid  particles 
in  the  air  in  various  occupations.  To  the  disease  caused  by 
inhalation  the  term  "  pneumonokoniosis  "  has  been  applied, 
while  special  names  are  given  according  to  the  nature  of  the 
inhaled  particles:  Anthracosis,  due  to  the  inhalation  of  coal- 
du.st;  sidcrosis,  due  to  iron-dust;  cha'icosis,  due  to  stone- 
du.st,  etc.  The  names  of  various  occupations  have  also 
been  attached,  such  as  "  miners'  phthisis,"  "  millers'  lung," 
"masons'  lung,"  "stone-cutters'  phthisis,"  "grinders'  rot," 
etc. 

Pathology. — The  lesion  consi.sts  in  the  growth  of  connec- 
tive tissue  which  replaces  the  normal  lung  structure.  The 
walls  of  the  air-spaces  and  of  the  bronchi  are  usually  first  in 
volved  by  connective-tissue  thickening,  so  that  the  air-spaces 
are  diminished  in  size,  are  frequently  deformed  by  polypoid 
projections  into  them  of  connective  tissue,  and  may  be 
effaced  entirely.  The  walls  of  the  bronchi,  losing  their 
ela.sticity,  may  dilate  to  form  bronchiectatic  cavities  who.se 
lining  may  be  mucous  membrane,  connective  tissue,  or  a 
suppurating  surface.  Similar  connective-tissue  changes  are 
usually  seen  in  the  pleura,  which  becomes  thickened  and 
adherent. 

The  new  connective  tissue,  having  scanty  blood-vessels, 
replaces  vascular  lung-ti.ssue,  so  that,  the  number  of  blood- 
channels  between  the   right  and  the  left  heart  becoming 


INTER STiriAL    PNEUMONfA.  3I9 

reduced,  there  may  either  be  a  compensatory  hypertrophy 
of  the  right  ventricle,  or  its  dilatation  with  general  venous 
congestions.  The  unaffected  portions  of  the  lung  are  apt 
to  be  emphysematous. 

The  appearance  of  the  lung  varies  with  the  cause  of  the 
pneumonia. 

1.  Interstitial  Pnaimonia  due  to  the  Inhalation  of  Dust. — 
The  connective  tissue  thickening  occurs  in  the  walls  of  the 
bronchi  and  of  the  surrounding  air-spaces.  Later  there 
may  be  areas  of  different  interstitial  pneumonia,  rendering 
more  or  less  of  the  lung  solid.  The  affected  areas  are 
stained  by  the  deposit  of  the  irritating  dust-particles ;  the 
bronchial  glands  are  inflamed  and  contain  the  offending  par- 
ticles.    Bronchiectatic  cavities  frequently  occur. 

2.  Interstitial  Pneumonia  foil ozving  Bronclio-pneiimonia. — 
Here  the  chronic  lesion  follows  the  localities  of  the  acute 
form.  The  walls  of  the  bronchi  are  involved  and  frequently 
are  dilated ;  there  are  peribronchial  fibrous  nodules,  with 
occasionally  diffused  areas  of  interstitial  pneumonia.  The 
process  may  be  entirely  peribronchial  or  it  may  involve  a 
whole  lobe. 

3.  Interstitial  Pneumonia  due  to  Lobar  Pneumonia. — These 
are  the  rare  cases  in  which  the  exuded  products  in  the  air- 
spaces become  organized,  so  that  the  lobe  is  rendered 
permanently  solid. 

4.  Intej'stitial  Pneumonia  folloiving  Chronic  Pleurisy. — 
In  this  form  the  pleura  is  much  thickened,  and  from  it  bands 
of  connective  tissue  pass  into  the  substance  of  the  lung. 

5.  Interstitial  Pneumonia  folloiving  Chronic  Bronchitis. — 
Here  the  walls  of  the  bronchi  are  thickened  and  dilated 
with  fibrous  nodules  about  the  bronchi. 

The  symptoms  begin  gradually.  There  is  a  chronic 
bronchitis  with  a  cough  and  with  mucous  or  muco-purulent 
expectoration  which  may  be  fetid.  There  may  be  small 
repeated  haemoptyses.  If  there  be  bronchiectatic  cavities, 
the  expectoration  will  be  more  profuse,  and  from  time  to  time, 
frequently  after  bending  over  or  after  any  change  in  posi- 
tion, a  large  quantity  of  secretion  will  be  expectorated. 

Fever  is  not  present  except  during  acute  exacerbations  of 


the  broncliitis  and  from  suppurating  bronchicctatic  cavities. 
In  the  latter  case  the  fever  nia\-  assume  the  hectic  type, 
with  night- sweats  and  emaciation  similar  to  the  septic  symp- 
toms so  commonly  observed  in  pulmonar)'  phthisis. 

Pain  in  the  chest  is  common  if  the  pleura  be  inxolved. 
Dyspnoea  is  usually  present,  depending  upon  the  extent 
of  lung  involved  and  the  condition  of  the  right  heart. 
Should  dilatation  of  the  right  heart  occur,  there  will  be  the 
general  venous  congestions  regularly  observed  in  this  con- 
dition. 

The  physical  signs  vary  according  to  the  actual  condi- 
tion of  the  lung.  The  bronchitis  gives  rise  to  coarse  and 
subcrepitant  rales  with  sibilant  or  sonorous  breathing. 

The  fibrous  areas  give  the  regular  signs  of  consolidation — 
dulness  on  percussion,  increased  vocal  fremitus,  and  bron- 
chial voice  and  breathing.  If  the  areas  be  small,  the  note 
may  be  tympanitic  and  the  breathing  sounds  may  be  feeble 
or  harsh  or  broncho-vesicular. 

Dilatation  of  the  bronchi  gives  rise  to  the  ph)sical  signs 
of  cavities — tympanitic  or  "  cracked-pot "  note,  more  rarely 
a  note  of  amphoric  quality,  with  cavernous  breathing,  inten- 
sified voice,  and  bubbling  rales  of  large  size. 

The  thickened  pleura  causes  dulness  or  flatness  on  per- 
cussion, while  vocal  fremitus,  breathing,  and  voice  are 
diminished  or  lost.  There  are  also  creaking,  rubbing  fric- 
tion-sounds of  all  kinds. 

From  shrinkage  of  the  connective  tissue  the  affected  areas 
are  reduced  in  size,  so  that  there  is  a  retraction  of  the  chest- 
wall  and  limited  respiratory  expansion,  in  strong  contrast  to 
the  unaffected  side.  There  may  be  overlapping"  of  the  ribs 
and  spinal  curvatures.  The  heart  may  be  displaced  b)' 
being  drawn  to  the  affected  side,  or  the  area  of  impulse  may 
be  abnormally  visible  should  the  lung  over  it  be  retracted. 

Prognosis. — The  disease  lasts  for  years,  the  more  severe 
cases  being  semi-invalids.  There  is  always  danger  of  an 
added  tubercular  infection,  to  which  these  lungs  are  exceed- 
ingly liable.  If  large  areas  of  lung  are  involved,  there  is 
always  danger  of  dilatation  and  failure  of  the  power  of  the 
right  heart.     Patients,  moreover,  are  apt  to  do  badly  if  the>' 


INTERLOBULAR  AND    VESICULAR  EMPHYSEMA.     32 1 

develop  acute  inflammation  of  the  remaining  portions  of  the 
lung. 

Treatment. — The  only  thing  that  can  be  done  is  to  send 
the  patient  to  a  mild  climate  where  the  bronchitis  will  not 
be  aggravated  by  exposure  to  cold  and  dampness.  If  this 
cannot  be  done,  the  general  nutrition  of  the  patient  should 
be  improved  in  every  way,  and  the  chronic  bronchitis 
treated. 

INTERLOBULAR   EMPHYSEMA. 

Etiology. — Interlobular  emphysema  usually  follows  severe 
expiratory  efforts,  as  in  whooping-cough,  and  is  most  fre- 
quently seen  in  the  broncho-pneumonia  of  young  children. 
The  disease  has  also  occurred  as  the  result  of  straining 
efforts  with  closure  of  the  glottis  in  parturition,  excessive 
muscular  exertions,  and  convulsions. 

Patholog-y. — By  rupture  of  the  air-spaces  air  escapes 
into  the  interlobular  septa,  rupturing  into  the  pleural  cavity 
to  cause  pneumothorax,  or  extensively  infiltrating  the  con- 
nective-tissue septa  and  compressing  the  parenchyma  of  the 
lung.  In  rarer  cases  it  may  make  its  way  into  the  medias- 
tinum and  extend  up  the  course  of  the  trachea  to  the  sub- 
cutaneous tissues  of  the  neck. 

The  symptoms  are  not  distinctive.  Pneumothorax  may 
result,  and  severe  cases  may  be  followed  by  sudden  death. 

VESICULAR    EMPHYSEMA. 

-There  are  three  distinct  forms  of  vesicular  emphysema — 
compensatory,  substantive,  and  senile. 

Compensatory  Emphysema. — When  part  of  the  lung  is 
so  disabled  that  it  cannot  expand  fully,  the  remaining  por- 
tions have  to  expand  or  the  chest-wall  will  fall  in.  Com- 
pensatory emphysema  consists,  then,  simply  in  an  over- 
stretched condition  of  the  lung,  with  distended  air-vesicles 
whose  walls  are  thinned.  It  occurs  as  a  temporary  con- 
dition in  pneumonia,  broncho-pneumonia,  and  with  pleuritic 
effusions.  When  the  cause  is  more  permanent,  as  with 
phthisis,  pleural  adhesions,  and  interstitial  pneumonia, 
groups  of  air-vesicles  may  remain  permanently  distended. 

21 


This  form  is  a  normal  compensatory  process,  gives  no 
symptoms,  subsides  with  the  subsidence  of  the  original 
disease,  and  is  of  no  })ractical  detriment  to  the  patient. 

Substantive  Emphysema. — Etiology. — Much  uncertainty 
exists  as  to  the  true  nature  of  substantive  emphysema. 
Formerly  it  was  regarded  as  a  mechanical  over-inflation  of 
the  lung  from  forced  inspiratory  or  expiratory  efforts.  This 
condition  argued  some  weakness  of  the  lung-tissue,  so  that 
it  was  supposed  that,  to  account  for  the  over-inflation,  there 
must  be  a  congenitally  weak  lung-tissue ;  this  theory  ap- 
peared to  be  borne  out  by  the  markedly  hereditary  char- 
acter of  the  disease.  It  was  found,  however,  that  there  were 
cases  of  emphysema  without  any  dilatation  of  the  air-spaces, 
so  that  this  could  not  be  regarded  as  an  essential  feature. 
Delafield  describes  the  disease  as  a  chronic  interstitial  in- 
flammation of  the  lung,  with  which  condition  more  or  less 
dilatation  of  the  air-spaces  is  usually,  but  not  invariably, 
associated.  His  studies  have  been  so  extensive  and  thor- 
ough that  his  descriptions  of  the  disease  process  will  be 
followed  to  the  exclusion  of  other  theories. 

Pathology. — The  lungs  are  large,  downy  or  feathery  to 
the  feel,  and  do  not  collapse  when  the  chest  is  opened. 
Enlarged  air-vesicles  are  usually  visible,  especialh'  along 
the  anterior  margins,  and  on  the  inner  surface  of  the  lobe 
near  the  root  of  the  lung.  In  some  cases,  however,  there 
is  no  dilatation  of  the  air-spaces,  and  these  cases  may  even 
be  attended  by  most  marked  symptoms  of  emphysema  dur- 
ing life.  The  walls  of  the  air-spaces  are  thickened  in  sonie 
parts  of  the  lungs,  thinned  in  others,  and  the  epithelial 
cells  lining  them  are  often  increased  in  size  and  number. 
Atrophic  changes  in  the  walls  of  the  vesicles  allow  of  per- 
foration, so  that  a  number  of  vesicles  may  merge  into  a  com- 
mon air-chamber.  With  the  atrophy  of  areas  of  the  vesic- 
ular wall  there  is  a  disappearance  of  the  capillaries  coursing 
over  it,  so  that  the  number  of  channels  between  the  right 
and  the  left  heart  becomes  materially  reduced.  In  many 
cases  there  exists  a  contraction  of  the  smaller  arteries, 
which  still  further  increases  the  pulmonary  obstruction. 
The  septa  between  the  lobules,  the  connective  tissue  around 


VESICULAR   EMPHYSEMA.  323 

the  bronchi  and  the  blood-vessels,  and  the  pulmonary  pleura 
are  often  considerably  thickened,  and  frequently  there  arc 
adhesions  between  the  pleural  surfaces.  There  is  regularly 
a  chronic  catarrhal  bronchitis,  but  bronchiectasis  is  not 
common.  There  may  be  endarteritis  of  the  branches  of  the 
pulmonary  or  bronchial  arteries,  and  it  is  supposed  that 
in  many  cases  spasmodic  contraction  of  these  arteries  occurs 
during  the  life  of  the  patient. 

Secondary  lesions  result  from  the  mechanical  obstruction 
to  the  pulmonary  circulation,  both  from  the  disappearance 
of  some  of  the  capillaries,  and  also  from  the  contraction  of 
the  small  arteries  ;  these  lesions  consist  in  the  hypertrophy 
and  dilatation  of  the  right  side  of  the  heart.  If  dilatation 
and  heart  failure  occur,  there  will  be  venous  congestions  of 
the  skin,  the  serous  membranes,  and  the  viscera.  The  con- 
dition of  the  right  heart — whether  compensatory  hypertro- 
phy occurs  and  remains  established — is  of  the  greatest  im- 
portance to  the  patient. 

Associated  lesions  are  usually  found.  They  consist  of 
chronic  endocarditis,  chronic  endarteritis,  and  chronic 
diffuse  nephritis.  These  lesions  depend,  as  does  emphy- 
sema, upon  the  slow  production  of  connective  tissue 
replacing  pre-existing  tissues,  and  they  are  therefore  apt  to 
be  associated  in  the  same  patient. 

Symptoms. — Of  the  regular  symptoms,  dyspnoea  is  the 
most  prominent.  At  first  the  dyspnoea  is  induced  only  by 
exertion,  by  indigestion,  or  by  attacks  of  bronchitis ;  later 
it  becomes  more  steady  and  troublesome.  Many  of  the 
attacks  of  dyspncea  appear  to  be  due  to  contraction  of  the 
small  arteries  of  the  lung. 

Symptoms  of  bronchitis  are  present,  especially  in  the 
winter  months.  The  patient  has  a  paroxysmal,  ineffectual 
cough,  with  muco-purulent  expectoration.  Exacerbations 
of  the  bronchitis  are  accompanied  by  an  increase  of  the 
cough  and  the  expectoration,  and  possibly  by  slight  fever, 
night-sweats,  and  rarely  by  small  hsemoptyses.  Should 
bronchiectatic  cavities  form,  they  are  marked  by  a  charac- 
teristically profuse  expectoration  after  change  of  position 
and  by  physical  signs. 


324        M.LVL'AL    OF  THE  PRACTICE    OF  MEDICINE. 

Symptoms  of  asthma  are  commonly  present ;  they  are 
usually  most  severe  during  the  exacerbations  of  the  bron- 
chitis. 

The  respirations  are  labored  and  wheezy ;  expiration  is 
unduly  prolonged.  The  obstruction  in  the  pulmonary  sys- 
tem allows  of  cyanosis,  often  of  an  extreme  grade,  but  it  is 
not  incompatible  with  comparative  comfort. 

When  compensation  fails  and  the  right  heart  dilates, 
general  venous  congestions  are  gradualh'  developed — con- 
gestion and  oedema  of  the  skin,  congestion  of  the  stomach, 
the  liver,  and  the  kidne}'s,  and  general  dropsy. 

The  s)-mptoms  of  chronic  endarteritis,  of  chronic  endo- 
carditis, or  of  chronic  diffuse  nephritis  ma\-  complicate  the 
course  of  the  disease  and  ma\'  even  obscure  the  diagnosis. 

Variations  in  the  Course  of  the  Disease. — The  follow- 
ing clinical  types  of  the  disease  are  described  by  Delafield : 

"  I.  Some  patients  for  years  have  a  winter  cough,  with  ex- 
pectoration of  mucus  and  sometimes  of  a  little  blood.  They 
are  always  a  little  short  of  breath  when  they  exert  them- 
selves. After  a  time  they  have  attacks  of  spasmodic  asthma. 
Then  the  dyspncea  on  exertion  becomes  more  constant  and 
more  decided  ;  the  patients  lose  flesh  and  strength  ;  venous 
congestion  is  established,  drop.sy,  and  death. 

"  2.  Other  patients  are  fairly  well  except  when  they  have 
attacks  of  acute  bronchitis.  Such  attacks  may  be  mild, 
lasting  a  few  days  or  a  few  weeks,  with  cough,  mucous  ex- 
pectoration, sometimes  hasmoptyses,  asthmatic  breathing, 
and  a  febrile  movement ;  or  the  attacks  may  be  severe,  and 
last  two  or  three  months,  and,  in  addition  to  the  symptoms 
ju.st  mentioned,  they  develop  venous  congestion,  albumi- 
nuria, and  dropsy. 

"3.  In  some  patients  there  is  a  history  of  attacks  of 
spasmodic  asthma  for  a  number  of  years  before  the  symp- 
toms of  emphysema  make  their  appearance. 

"  4.  In  some  patients  the  evidences  of  emphysema  are 
very  slight  for  a  long  time.  Then  rather  suddenly  constant 
dyspnoea  and  venous  congestion  are  developed,  and  the 
patients  die  in  a  {&\\  months." 

Physical  Sig-ns. — Inspection  may  reveal  nothing  abnor- 


VESICULAR    F.MPnYSF.MA.  325 

mal.  In  advanced  cases  there  is  an  increase  in  the  antero- 
posterior dimensions  of  the  thorax,  approaching  the  "  barrel- 
shaped  chest "  in  some  cases.  The  chest  rises  and  falls 
en  masse  ■ixwdi  with  evident  muscular  action,  dyspnoea  being 
evident.  Lateral  expansion  is  not  well  marked.  The  head 
inclines  forward,  the  shoulders  are  rounded,  the  sterno- 
cleido-mastoid  muscles  are  prominent,  and  the  respiratory- 
action  of  the  diaphragm  is  increased.  The  thorax  in  em- 
physema has  aptly  been  described  as  one  of  "  permanent 
inspiration." 

Pulmonary  resonance  may  be  unchanged  or  vesiculo- 
tympanitic, or  there  may  exist  an  exaggerated  resonance  of 
a  tympanitic  quality,  or  the  resonance  may  be  of  a  variety 
of  tympany  of  a  dull  quality.  This  latter  note,  often  called 
"  wooden,"  is  highly  characteristic.  The  percussion  bound- 
aries of  the  lung  are  increased  in  all  dimensions,  and,  owing 
to  the  increased  thickness  of  the  covering  lung,  the  borders 
of  the  heart  are  determined  with  great  difficulty. 

The  characteristic  breathing  is  feeble  compared  with  the 
evident  expansion  of  the  chest;  the  expiration  is  much 
longer  than  inspiration,  and  is  of  a  lower  pitch.  More 
rarely  both  inspiration  and  expiration  may  be  harsh,  loud, 
and  high-pitched. 

Sibilant  and  sonorous  rales  are  usually  present,  and  the 
bronchitis  adds  coarse  mucous  rales. 

Prognosis. — Substantive  emphysema  is  essentially  ch  ronic, 
its  course  extending  over  years.  Moderate  degrees  of  em- 
physema are  not  incompatible  with  prolonged  and  active 
life,  but  in  each  case  the  questions  must  be,  How  much 
extra  work  is  thrown  upon  the  right  heart  ?  and,  How  long 
can  compensation  be  maintained?  Due  regard  should  also 
be  had  for  the  presence  of  associated  diseases — diseased 
arteries,  heart,  and  kidneys. 

Treatment. — Much  can  be  done  to  check  the  course  of 
the  disease  by  sending  the  patient  to  some  warm  inland 
place  for  the  winter  months  at  least,  where  he  can  lead  a 
life  out  of  doors  and  not  contract  recurring  attacks  of  bron- 
chitis.    The   general   health   should   be   built    up  in   every 


26       M.-lXi'AL    OF   THE   PKACriCE    OF  MEDICINE. 


way  ;  over-use  of  tobacco  and  of  stimulants  is  to  be  inter- 
dicted ;  starches  and  sugars  should  be  avoided. 

Attacks  of  dyspnoea  are  best  controlled  by  drugs  that 
dilate  the  small  arteries — chloral  hydrate,  iodide  of  potas- 
sium, and  nitroglycerin.     A  good  combination  is  as  follows  : 

R.    Liq.  morph.  sulph.  (Magendie),     TTlj  ; 
Tinct.  belladonnse,  TTliijr 

Potassii  iodidi.  gr.  vij  ; 

Spiritus  iutheris  comp.,  TTLxv; 

Aqua;,  3SS. — M. 

Sig.    Such  a  dose  every  three  or  four  hours. 

Bronchitis  is  to  be  treated  on  general  principles.  Should 
the  cough  be  harassing,  the  fluid  extract  of  chekan,  in 
dram  doses  every  three  hours,  is  often  of  the  greatest  ser- 
vice. The  fluid  extract,  desiccated  and  given  in  capsule,  is 
a  conv^enient  and  pleasant  form  of  administration.  Ter- 
pin  and  the  turpentine  derivatives  are  of  service  should 
the  expectoration  be  profuse. 

When  the  right  heart  begins  to  fail  and  venous  conges- 
tions appear,  cardiac  stimulants  are  indicated.  Of  these 
strychnine  is  especially  useful.  The  bowels  should  be  kept 
freely  open,  and  all  tendency  to  flatulent  dyspepsia  is  to  be 
combated  by  diet  and  drugs.  Should  the  venous  conges- 
tions be  urgent  and  the  patient  be  fairly  robust,  free  bleed- 
ing is  often  followed  by  marked  improvement. 

GANGRENE  OF  THE  LUNG. 
Etiology. — Gangrene  of  the  lung  is  caused  by  infection 
by  means  of  the  putrefactive  bacteria.  As  these  germs  are 
so  common  in  inspired  air,  a  condition  of  impaired  lung- 
vitality  must  be  presupposed.  The  disease  is  most  com- 
monly caused  by  the  entrance  of  organic  foreign  bodies 
into  the  bronchi,  from  food  or  other  bodies  being  inhaled 
into  the  trachea,  from  "  aspiration-  "  or  "  deglutition-pneu- 
monia," or  from  the  perforation  of  the  lung  by  cancer  of 
the  oesophagus  or  of  the  stomach.  It  may  follow  cavities, 
bronchiectasis,  or   fetid  bronchitis.     It  occasionally  follows 


GANGRENE    OF   THE   LUNG.  327 

embolism  or  pressure  of  the  branches  of  the  pulmonary  or 
the  bronchial  arteries,  and  it  is  one  of  the  rare  sequehu  of 
lobar  pneumonia.  Exceptionally  it  occurs  in  debilitated 
subjects,  especially  those  with  diabetes,  without  antecedent 
pulmonary  disease. 

Pathology. — A  circumscribed  and  a  diffuse  form  are 
recognized. 

The  circuviscribcd  {oxvi\  occurs  in  single  or  multiple  foci, 
usually  in  the  lower  lobe  near  the  periphery.  The  gan- 
grenous area  is  converted  to  a  greenish-brown  offensive 
mass  surrounded  by  congested  or  consolidated  lung- 
tissue.  The  neighboring  veins  are  frequently  filled  with 
infective  thrombi  that  may  become  detached,  causing  sec- 
ondary foci  in  other  parts  of  the  body.  In  this  way  abscess 
of  the  brain  may  be  developed.  If  the  pleura  be  involved, 
pleurisy  with  a  sanious  or  purulent  effusion  will  result,  or 
perforation  of  the  pleura  will  lead  to  pyo-pneumothorax. 
Severe  and  even  fatal  hemorrhage  will  result  from  erosion 
of  a  large  arterial  branch.  An  intense  general  bronchitis 
always  complicates  the  disease.  Liquefaction  of  the  gan- 
grenous area  rapidly  occurs,  and,  the  softened  portions 
being  coughed  up,  a  cavity  with  ragged  necrotic  walls  is 
left.  Should  the  patient  recover,  a  connective-tissue  cap- 
sule forms,  enclosing  the  cavity,  which  may  subsequently 
contract. 

The  diffuse  form  may  be  so  from  the  start  or  may  follow 
the  circumscribed  form.  A  lobe  or  the  greater  part  of  a 
lobe,  or  even  the  entire  lung,  may  thus  become  gangrenous. 
The  diffuse  form  rarely  follows  lobar  pneumonia. 

Symptoms. — Pidinonary. — There  is  a  cough  with  an  ex- 
pectoration which  is  fetid  and  usually  abundant.  On  stand- 
ing, the  expectoration  separates  into  three  layers — an  upper 
layer,  frothy  and  opaque  ;  a  middle  layer,  clear  and  watery, 
and  usually  of  a  greenish  or  brownish  tinge ;  and  a  lower 
layer,  of  a  greenish  sediment  which  consists  of  mucus,  pus, 
shreds  of  elastic  lung-tissue,  granular  matter,  crystals  of 
fatty  acids,  and  bacteria. 

Blood  is  often  present  in  the  sputa,  and  large  hemorrhages 


328        MAXi'AL    OF   THE   PA'ACT/CE    OF  MEDICLXE. 

may  occur.  Marked  and  characteristic  fetor  of  the  breath 
is  rarely  absent.     Pain  occurs  if  there  be  pleurisy. 

Septic. — There  is  developed  an  irregular  fever  with  pros- 
tration. The  patient  loses  flesh  and  strength  and  passes 
into  a  typhoid  condition.  In  cases  in  which  the  gangrenous 
area  is  encapsulated  the  septic  symptoms  are  not  so  severe 
as  one  would  expect. 

The  physical  signs  are  those  of  consolidation  over  a  cer- 
tain area,  followed  b\-  the  signs  of  a  pulnionar}'  cavit)'. 
There  are  abundant  moist  bronchial  rales.  Physical  signs 
of  pleurisy  with  effusion  or  of  p)'o-pncumothorax  may  be 
present. 

The  diagnosis  from  fetid  bronchitis  is  made  by  finding 
shreds  of  pulmonary  tissue  and  elastic  fibres  in  the  sputum. 

The  prognosis  is  bad,  but  not  hopeless.  The  course  may 
be  acute,  or  the  di.sease  may  last  for  months. 

Treatment  consists  in  supporting  the  strength  of  the 
patient  and  in  disinfecting  the  lung  as  thoroughly  as  our 
limited  means  will  permit.  The  patient  should  wear  con- 
tinuously a  Robinson  inhaler  saturated  with  equal  parts  of 
alcohol,  creosote,  and  chloroform.  Terpin  and  the  deriva- 
tives of  turpentine  are  often  of  great  service,  while  nn-rtol, 
(gr.  iiss  in  capsule  every  two  hours)  is  warmh-  advocated. 

If  the  gangrenous  area  be  localized  near  the  surface  of 
the  lung,  injections  of  antiseptics  may  be  made  directly 
into  it,  and  if  the  patient  be  in  fair  condition,  the  cavity 
may  be  opened  through  the  chest-wall  and  drained. 

ABSCESS    OF    THE    LUNG. 
Etiology. — Aside  from  the  cases  of  purulent  infiltration 
complicating  lobar  pneumonia  or  broncho-pneumonia,  ab- 
scess of  the  lung  may  occur  from  the  following  causes: 

1.  From  the  introduction  of  foreign  septic  substances  into 
the  bronchi,  as  in  aspiration- or  deglutition-pneumonia,  from 
septic  diseases  of  the  throat  or  the  neck,  from  perforation  into 
the  lung  of  cancer  of  the  oesophagus  or  the  stomach  or  ab- 
scess of  the  liver,  or  from  penetrating  wounds  of  the  thorax. 

2.  It  may  complicate  lobar  pneumonia  or  phthisis,  or  it 
may  be  due  to  the  suppuration  of  an  echinococcus  cyst. 


SYPIf/L/S    OF    77 IF.    LUXG.  329 

3.  More  commonly  abscess  of  the  lung  results  from  infec- 
tive emboli,  the  so-called  "embolic"  or  "  metastatic  abscess." 
Multiple  abscesses  frequently  occur  with  pyaemia  or  with 
malignant  endocarditis  involving  the  right  heart.  At  first 
the  lesion  resembles  an  ordinary  hemorrhagic  infarction, 
but  the  embolic  area  rapidly  becomes  purulent  and  softens 
to  form  a  cavity,  while  the  pleura  over  it  becomes  infected, 
resulting  usually  in  empyema  or  pyo-pneumothorax- 

The  symptoms  are  frequently  masked  by  those  of  the 
original  disease.  Respirations,  however,  are  quickened,  the 
temperature  becomes  higher,  and  the  patient  is  evidently 
much  worse.  Pain,  if  present,  is  due  to  the  pleurisy.  Em- 
pyema or  pyo-pneumothorax  may  add  its  symptoms.  The 
sputum  is  abundant,  purulent,  and  contains  shreds  of  lung- 
tissue.  The  odor  is  offensive,  but  not  so  markedly  so  as  in 
fetid  bronchitis  or  in  gangrene  of  the  lung.  The  constitu- 
tional symptoms  are  those  of  sepsis. 

The  physical  signs  at  first  are  those  of  consolidation,  be- 
coming changed  later  to  those  of  a  cavity.  Complicating 
pleurisy  with  effusion  or  pyo-pneumothorax  adds  its  charac- 
teristic physical  signs. 

The  prognosis  is  almost  always  fatal  in  embolic  cases, 
but  recovery  occasionally  occurs  after  pneumonia.  Prompt 
and  efficient  treatment,  however,  may  moderate  the  mortal- 
ity rate. 

The  treatment  should  be  entirely  surgical,  consisting  in 
the  opening  and  draining  of  the  abscess-cavity.  Recovery 
or  improvement  results  in  about  one-half  the  cases  so 
treated. 

SYPHILIS  OP   THE  LUNG. 

Syphilis  of  the  lung  is  a  rare  disease,  but  its  actual 
occurrence  is  undoubted. 

Pathology. — Three  distinct  forms  of  lung-syphilis  are 
recognized  : 

I.  White  Hepatization,  or  White  Pneumonia. — This  form 
is  seen  in  stillborn  children  with  other  evidences  of  heredi- 
tary syphilis.  The  lesion  consists  in  the  infiltration  and 
thickening  of  the   walls   of  the   alveoli,  the  blood-vessels, 


330        M.lXi\4L    OF  THE   PRACTICE    OF  MEDICINE. 

and  the  bronchi  with  small  cells.  Some  of  the  air-spaces 
are  filled  with  epithelial  cells.  These  cases  are  of  patho- 
logical rather  than  of  clinical   interest. 

2.  Gu)}unata  may  occur  m  the  lung  as  a  late  tertiary 
manifestation.  The  gummata  are  distributed  through  the 
lungs  and  are  especially  numerous  at  the  bases ;  they  vary 
from  a  microscopical  size  to  that  of  a  lemon.  Each  gumma 
is  usually  surrounded  by  a  zone  of  consolidation.  There 
are  usually  a  general  bronchitis,  thickened  pleura,  and  some 
interstitial  pneumonia  as  complicating  lesions. 

Destructive  syphilitic  processes  in  the  lung  have  not  as 
yet  been  proved.  Cases  of  gummatous  pneumonia  re- 
semble, clinically,  tubercular  broncho-pneumonia  or  new 
growths  of  the  lung. 

3.  Sypliilitic  Fibroid  Pncunwfiia. — In  this  form  the  pleura 
is  thickened,  and  bands  of  connective  tissue  extend  from  it 
into  the  lung.  The  bronchi  are  surrounded  by  a  growth  of 
connective  tissue,  which  may  either  so  compress  them  as  to  . 
cause  urgent  dyspnoea  or  may  weaken  them  and  allow  of  their 
dilatation.  Patches  of  indurated  connective  tissue  may  re- 
place the  lung-parench)'ma,  rendering  certain  portions  of  the 
lung  completely  solid.  All  these  lesions  are  found  especially 
well  marked  at  the  base  of  the  lung.  The  physical  signs 
are  those  of  bronchitis,  bronchiectatic  cavities,  thickened 
pleura,  and  areas  of  consolidation. 

The  treatment  is  that  of  tertiary  syphilis,  but  it  is  usually 
ineffective.  The  course  of  the  disease  is  slow,  and  the 
termination  is  usually  fatal. 

NETAT  GROWTHS  OP  THE  LUNG. 

The  most  common  forms  of  neoplasms  of  the  lung  are 
carcinoma,  especially  of  the  epithelial  variety,  and  sarcoma; 
more  rarely  are  found  enchrondroma  and  osteoma.  Primary 
growths  are  exceedingly  rare. 

Primary  carcinoma  is  usually  found  as  a  single  growth  at 
one  apex ;  it  may  involve  other  organs  by  metastasis 
through  the  medium  of  the  bronchial  glands,  or  it  may 
involve  the  pleura  and  the  chest-wall  by  direct  extension. 

Secondary     carcinoma      occurs     as     scattered     nodules 


NEW  GROWTHS   OF   THE   LUNG.  33 1 

through  out  both  lungs,  each  nodule  being  surrounded 
by  a  zone  of  congested  and  consolidated  lung-tissue. 
Either  a  simple  or  a  malignant  pleurisy  usually  compli- 
cates the  lesion. 

Sarcoma  is  usually  secondary,  and  both  lungs  are  involved 
by  scattered  nodules.  The  sarcoma  is  usually  of  the  small- 
celled  variety. 

Symptoms. —  i.  Symptoms  due  to  involvement  of  the  lungs 
depend  on  the  size,  number,  and  position  of  the  malignant 
growths.  If  the  nodules  be  small  and  scattered,  the  patient 
will  complain  of  dyspnoea  and  of  pain  in  the  chest  from  the 
complicating  pleurisy,  and  will  develop  a  cough.  The 
expectoration  is  either  muco-purulent  or  bloody,  or  per- 
haps dark  and  mucoid,  the  so-called  "prune-juice"  expec- 
toration, which  is  highly  suggestive.  In  other  cases  the 
expectoration  resembles  currant-jelly,  and  this  appearance 
is  almost  pathognomonic.  In  the  expectoration  cancer- 
cells  may  be  found. 

2.  Large  single  growths  may  cause  pressure-symptoms. 
Pressure  on  the  bronchi  will  cause  cough,  expectoration, 
haemoptysis,  and  dyspnoea.  Pressure  on  the  vena  cava 
will  cause  congestion  and  oedema  of  the  arm,  the  neck, 
and  the  upper  portion  of  the  thorax.  Pressure  on  the 
oesophagus  will  cause  dysphagia.  Pressure  on  nerves  will 
cause  intercostal  neuralgia.  If  the  recurrent  larj'ngeal 
nerve  be  involved,  the  patient  will  develop  a  brassy  cough, 
laryngeal  voice,  and  steady  or  paroxysmal  dyspnoea. 

3.  Cancerous  cachexia  will  be  shown  by  a  waxy  pallor, 
loss  of  strength,  slight  afternoon  fever,  and  oedema  of  the 
ankles. 

4.  There  may  be  added  the  symptoms  of  primary  or  sec- 
ondary growths. 

Physical  Signs. — Inspection  may  reveal  distended  veins 
of  the  upper  thorax  and  the  neck  or  bulging  of  the  chest- 
wall,  which  may  be  mistaken  for  aneurysm,  especially  as 
the  bulging  part  may  yield  a  slight  expansile  pulsation  or 
an  appreciable  transmitted  expansion.  There  may  be  infil- 
trated cervical  or  axillary  glands,  and  the  seat  of  the  primary 
growth  may  be  detected. 


^}2        .U.IXC'.I/.    OF    THE   PRACTICE    OE  MEDICLXE. 

Physical  signs  depend  upon  the  size  and  position  of  the 
tumors. 

1.  There  ma)-  be  only  the  ph)-sical  signs  of  a  bronchitis 
with  those  of  a  dry  pleurisy  or  of  an  effusion  which  in  some 
cases  is  hemorrhagic. 

2.  Larger  nodules  give  rise  to  the  signs  of  scattered  areas 
of  consolidation. 

3.  A  single  large  growth  will  give  rise  to  an  area  of  flat- 
ness, with  absence  of  voice  and  breathing,  surrounded  by  an 
area  of  dulness,  with  bronchial  voice  and  breathing.  The 
central  flat  area  is  usual!}-  exquisite!}'  tender  on  percussion. 

The  prognosis  is  fata!  in  from  six  months  to  two  years. 

Treatment  is  merely  palliative,  to  relieve  suffering.  In- 
jections of  the  toxic  products  of  the  er}'sipelas  coccus  may 
be  made  in  sarcomatous  cases. 

ECHINOCOCCUS  CYSTS  OF  THE  LUNG. 

Small  cysts  may  exist  for  a  considerable  time  without 
causing  symptoms.  Large  cysts  tend  to  compress  the  lung 
and  lead  to  secondar}-  inflammator}-  changes. 

Rupture  into  a  bronchus  will  allow  of  the  expectoration 
of  fragments  of  the  cvst-wall  and  of  the  hooklets,  estab- 
lishing the  diagnosis  without  doubt. 

Rupture  into  the  pleura  is  not  uncommon.  Suppuration 
of  the  cyst  may  occur,  and  gangrene  of  the  lung  is  not 
uncommon. 


ip)  Tubercular  Diseases  of  the  Lung. 

TUBERCULAR  INFLAMMATIONS   IN    GENERAL. 

Definition. — Tubercular  inflammation,  caused  by  infec- 
tion by  the  tubercle  bacillus,  is  characterized  by  the  pro- 
duction of  new  tissue  of  low  vitality. 

Etiology. — The  bacillus  tuberculosis,  first  described  in 
1 88 1  by  Koch,  is  now  definitely  proved  to  be  the  actual  cause 
of  tubercular  disease.  The  bacillus  is  a  short  fine  rod  having 
a  length  equal  to  one-half  the  diameter  of  a  red  blood-cell. 


TUBERCULAR   INFLAMMATIONS  IN  GENERAL.      333 

When  stained  it  presents  a  beady  appearance,  probably  due 
to  spore-growth  within  it.  For  the  methods  of  staining  the 
germ  the  reader  is  referred  to  works  on  bacteriology.  The 
bacilli  are  found  in  all  tubercular  lesions,  but  they  are  more 
numerous  in  the  acute  forms  of  disease.  They  may  gain 
access  to  the  blood-vessels  or  the  lymph-vessels,  and  become 
generally  distributed  throughout  the  body.  They  are  thrown 
off  in  the  expectoration  of  patients  suffering  from  pulmo- 
nary tuberculosis  in  enormous  numbers,  and  this  infected 
sputum,  when  allowed  to  dry,  enters  the  air  as  a  fine  dust, 
which  spreads  the  disease  in  every  direction  and  infects 
rooms,  carpets,  and  clothing. 

Modes  of  Infection. —  i.  Hereditary  or  congenital  tubercu- 
losis is  very  rare,  although  undoubted  cases  have  occurred. 

2.  Acquired  T?iberculosis. — (a)  By  Inhalation. — Inhalation 
is  the  most  common  method  of  infection,  as  is  proved  by 
the  fact  that  50  per  cent,  of  all  autopsies  show  some  degree 
of  tubercular  disease  of  the  lungs.  Cloisters,  prisons,  asy- 
lums, and  infected  houses  show  a  marked  increase  of  tuber- 
cular inhabitants.  The  expired  air,  however,  of  tubercular 
patients  is  not  infective. 

{b)  By  Inoculation. — Local  tubercular  lesions  may  result 
from  inoculation  incurred  by  handling  tuberculous  patholog- 
ical specimens,  infected  meat  and  skins,  and  by  wounds 
being  inoculated  by  impure  instruments  or  by  tubercular 
dust.  Many  cases  of  tuberculosis  in  children  have  followed 
the  rite  of  circumcision,  during  which  the  wound  has  been 
sucked  by  a  tuberculous  operator.  There  is  no  evidence 
that  tuberculosis  can  be  conveyed  by  vaccination  with 
humanized  virus. 

(c)  By  the  Ingestion  of  Tubercidous  Meat  or  Milk. — Strik- 
ing examples  of  the  infectious  properties  of  the  milk  of 
tuberculous  cows  are,  unfortunately,  only  too  common, 
many  cases  of  intestinal  and  mesenteric  tuberculosis  being 
directly  traceable  to  this  cause.  Meat  of  tuberculous  ani- 
mals is  not  always  infective,  and  the  process  of  cooking  in 
all  probability  affords  an  efficient  safeguard  against  this 
method  of  transmission. 

Conditions   Favorable    to    Infection. —  i.   Constitutional 


334        .^/.-t.yC-lL    OF   THE   PKACriCE    OF  MEDICIXE. 

Conditions. — [li)  A  family  history  of  tuberculosis  is  present 
in  from  lO  to  50  per  cent,  of  cases,  according  to  various 
authors.  .  It  is  hard  to  say,  however,  in  an\-  given  case, 
whether  the  child  was  born  with  some  inherent  tissue-weak- 
ness predisposing  toward  tubercular  infection — a  naturally 
good  soil  for  the  growth  and  development  of  the  bacilli — or 
whether  greater  risk  for  accidental  infection  was  run  from 
the  child  living  with,  kissing,  and  sleeping  with  tuberculous 
parents.  In  either  case,  however,  transmission  of  the  disease 
is  more  common  when  the  mother  is  tuberculous. 

(/;)  Tubercular  infection  is  more  common  among  weakly, 
sickly  subjects  with  deficient  chest-expansion.  Any  depre- 
ciation of  the  general  health  diminishes  the  resistance  of  the 
tissues  and  favors  infection.  It  is  found  that  rabbits,  by 
being  allowed  to  run  freely  in  the  woods,  may  be  kept  in 
such  perfect  condition  that  they  cease  to  be  good  subjects 
for  the  experimental  inoculation  of  the  bacilli. 

ic)  No  age  is  exempt,  but  in  children  tuberculosis  of  the 
bones,  the  lymphatics,  the  meninges,  and  the  intestinal  tract 
is  much  more  frequent  than  in  adults. 

id')  The  negro  affords  a  fertile  soil  for  the  growth  of  the 
bacilli,  and  tuberculosis  among  the  American  Indians  is 
especially  frequent. 

2.  Local  Conditions. — Any  local  weakness  or  inflammation 
renders  the  part  of  the  body  affected  more  susceptible  to 
tubercular  infection.  Bronchitis,  enlarged  bronchial  glands, 
and  interstitial  pneumonia  are  frequently  found  as  predis- 
posing causes  of  pulmonary  tuberculosis,  while  intestinal 
catarrh  produces  conditions  favorable  for  the  growth  of  the 
bacilli  in  the  alimentary  tract.  Local  injuries  or  operations 
may  so  weaken  the  tissues  as  to  allow  of  infection.  Thus 
a  simple  synovitis  from  injury  may  become  tubercular,  or 
pulmonary  tuberculosis  may  fallow  severe  contusions  of  the 
chest. 

Structure  of  Tubercle. — The  local  action  of  the  tubercle 
bacillus  upon  the  tissues  results  in  the  proliferation  of  pre- 
existing cells  and  in  the  aggregation  of  leucocytes.  To 
this  collection  of  cells  the  name  of  "  tubercle  "  is  given. 

The  first  step  in  the  formation  of  tubercle  consists  in  the 


rUBERCULAR   INFLAMMATIONS  IN  GENERAL.      335 

increase  in  number  of  the  fixed  normal  cells,  especially  those 
of  the  connective  tissue  and  the  endothelium  of  the  capillaries. 
These  proliferated  cells  are  known  as  "  epithelioid  cells." 
Giant-cells  are  formed  by  the  increase  in  protoplasm  and  in 
the  nuclei  of  a  single  cell  or  by  the  fusion  of  several  cells. 
Giant-cells  are  found,  however,  only  in  cases  in  which  the 
bacilli  have  a  low  degree  of  vitality. 

The  next  step  consists  in  the  emigration  from  the  neigh- 
boring blood-vessels  of  leucocytes  which  mix  with  or  sur- 
round the  above-mentioned  epithelioid  cells.  A  network  or 
reticulum  of  fibres  is  found  between  the  cells,  probably 
representing  the  original  interstitial  tissue  stretched  apart  by 
the  increased  cellular  elements.  The  reticulum  is  most 
marked  at  the  margin  of  the  tubercle.  No  new  blood-vessels 
are  formed  in  the  tubercular  growth,  and  pre-existing  blood- 
vessels are  apt  to  show  lesions  of  an  obliterating  endarteritis, 
so  that  the  newly-formed  tissue  has  but  feeble  vitality. 

When  these  changes  have  become  sufficiently  extensive 
the  tubercle  appears  as  a  grayish  point  or  nodule,  to  which 
the  name  "  miliary  tubercle  "  is  given.  By  the  growth  and 
approximation  of  these  miliary  tubercles  large  areas  may 
be  involved,  forming  the  so-called  "  diffuse  tubercle." 

Histologically,  tubercle  cannot  always  be  differentiated 
from  other  infectious  tumors,  such  as  those  of  syphilis  or 
leprosy,  or  from  ordinary  granulation-tissue.  Tubercle- 
tissue,  however,  is  characterized  by  its  natural  tendency 
toward  cheesy  degeneration. 

Cheesy  degeneration,  or  "  coagulation-necrosis,"  is  due 
partly  to  the  local  action  of  the  bacilli  upon  the  newly- 
formed  cells,  and  partly  to  the  scanty  blood-supply  of  the 
tubercular  nodule.  At  the  centre  of  the  nodule  the  cells 
die,  lose  their  nuclei  and  their  staining  properties,  and 
become  translucent  and  structureless.  This  area  of  degen- 
eration presents  an  opaque,  yellowish-white  appearance,  and 
by  the  extension  and  coalescence  of  these  areas  the  degen- 
eration may  become  exceedingly  extensive.  Subsequently 
the  degenerated  area  may  undergo  (i)  softening,  so  as  to 
form  a  cavity  or  an  ulcer,  (2)  encapsulation,  or  (3)  in  it  may 
be  deposited  the  salts  of  lime. 


336        MA.VLAL    OF   THE   PRACTICE    OE  MEDICIXE. 

SpofittDicoiis  hca/i)ig-  of  tiilnrcular  fiodulcs  may  occur  in 
two  waws  : 

1.  Tlvc  nodule  may  be  surrounded  b\-  a  fibrous  capsule; 
its  cheesy  centre  may  be  converted  to  a  putty-like  mass 
which  may  be  infiltrated  with  the  salts  of  lime ;  or  it  may 
liquefy  and  be  absorbed,  leaving  only  a  puckered  cicatrix. 

2.  There  may  be  a  great  increase  in  the  fibroid  elements 
of  the  nodules,  so  that  the  tubercle  becomes  firm,  hard,  and 
does  not  increase  in  size.  This  fibroid  or  sclerotic  change  is 
more  frequently  seen  in  tubercles  of  the  peritoneum. 

Secondary  Inflammatory  Processes. — Tubercle  seldom 
occurs  alone  in  the  tissues,  but  the  irritation  caused  by  its 
growth  produces  secondary  inflammatory  changes,  so  that 
the  tubercle  may  become  a  very  composite  structure. 

Symptoms  of  Tubercular  Disease. — The  action  of 
tubercle  bacilli  is  at  first  entireh*  local.  The  affected  area 
may  be  small,  and  the  resulting  symptoms  consequently 
slight  and  locahzed.  In  other  cases  the  local  lesion  may 
spread  by  continuity,  so  that  large  portions  of  important 
organs  may  be  rendered  unfit  to  fulfil  their  functions,  with 
resulting  symptoms  that  are  not  only  local  but  general. 
In  still  other  cases  the  lesion  is  at  first  localized,  but  from 
softening  and  breaking  down  of  a  tubercular  deposit  the 
bacilli  may  enter  a  blood-vessel  or  a  lymphatic,  enter  the 
general  circulation,  and  set  up  miliary  tubercles  wherever 
they  happen  to  lodge.  The  symptoms  resulting  from  such 
a  scattering  of  the  lesion  are  those  of  an  acute  infectious 
disease  combined  with  the  local  symptoms  of  tuberculosis 
in  different  parts  of  the  bod}\  This  form  is  spoken  of  as 
"  acute  miliary  tuberculosis  ;  "  it  is  considered  under  the 
heading  Infectious  Diseases.  The  danger  of  this  general 
infection  must  always  be  borne  in  mind  in  every  tubercular 
inflammation,  no  matter  how  localized  it  may  beat  the  onset. 

TUBERCULAR    DISEASES  OF  THE   LUNG. 

Under  this  heading  may  be  included — i.  Acute  pulmo- 
nary tuberculosis ;  2.  Chronic  pulmonary  tuberculosis ;  3. 
Acute  pulmonary  phthisis  ;  4.   Chronic  pulmonary  phthisis. 


'J'UBKRCULAK   /J/S/wlS/CS   OF    77//-:    7.UNG.  337 

ACUTK     PULMOXAKV    TUHMKCULOSIS. 

Etiology. — In  this  form  of  disease  the  bacilli  reach  the 
lung  either  through  the  inspired  air  or  by  being  transported 
by  the  blood.  In  the  latter  case  tubercular  involvement  of 
the  bronchial  glands  may  precede  the  pulmonary  tuber- 
culosis. In  other  cases  some  old  tubercular  process  is 
found  to  be  the  source  of  infection. 

Pathology. — Disseminated  tubercles  are  found  in  part 
of  a  lung  or  scattered  throughout  both  lungs.  Each  miliary 
tubercle  is  surrounded  by  a  slight  zone  of  congested  or 
consolidated  air-vesicles,  but  the  greater  part  of  the  inter- 
vening lung-tissue  is  comparatively  normal,  and  this  condi- 
tion sharply  defines  the  disease  from  pulmonary  phthisis, 
in  which  consolidation  of  the  intervening  lung-tissue  is  an 
early  lesion.  The  tubercles  usually  are  first  found  at  the 
apex  of  one  lung,  from  which  point  they  may  spread  ;  or 
tubercles  may  be  formed  at  once  throughout  both  lungs  in 
great  numbers.  There  is  always  a  catarrhal  inflammation 
of  the  finer  bronchi  of  that  portion  of  the  lung  occupied  by 
the  tubercles ;  in  rarer  cases  the  bronchitis  is  general. 
Tubercles  in  or  near  the  pulmonary  pleura  result  in  pleurisy 
either  with  fibrin  or  with  serous  effusion.  As  the  tubercles 
grow  and  coalesce,  portions  of  lung  may  be  rendered  solid, 
but  this  consolidation  is  always  a  late  manifestation  of  the 
disease.  From  areas  of  softening  breaking  into  one  another 
small  cavities  may  be  formed,  and  these  cavities  may  be 
still  further  increased  in  size  by  tubercular  ulceration  of  the 
bronchi  leading  into  them. 

Symptoms. —  i.  Cases  in  which  tubercles  are  rapidly 
formed  throughout  both  lungs  and  in  other  parts  of  the 
body  are  really  examples  of  acute  miliary  tuberculosis ; 
they  are  considered  in  the  discussion  of  that  disease. 

2.  The  term  "  pulmonar}^  tuberculosis  "  is  applied  more 
properly  to  those  cases  in  which  tubercles  spread  from  the 
apex  of  one  lung  and  are  not  found  in  other  parts  of  the 
body — a  purely  localized  process. 

In  some  cases  the  disease  may  develop  as  a  primary 
infection,  while  in  other  cases  it  complicates  some  pre-exist- 
22 


JO 


8        .V.I.VC.IL    OF   TJ/E   PRACTICE    OE  MEDICI XE. 


ing  tubercular  lesion.  When  the  disease  is  established  the 
symptoms  depend  upon  the  extent  of  lung  involved,  the 
bronchitis,  and  the  pleurisy. 

The  patient  has  a  fever,  higher  in  the  afternoon,  followed 
by  sweating  at  night.  The  heart's  action  is  rapid.  Breath- 
ing is  rapid  and  often  insufficient,  and  is  made  more  rapid 
by  extension  of  the  tuberculosis  or  by  increase  of  the  bron- 
chitis or  of  the  pleurisy.  However  rapid  the  breathing, 
there  is  not  apt  to  be  much  subjective  dyspnoea,  even 
though  there  be  marked  cyanosis.  Cough  is  a  fiiirly  con- 
stant symptom,  and  may  be  most  distressing.  The  expec- 
toration is  muco-purulent  and  may  contain  blood.  In  the 
sputa  the  bacilli  arc  usually,  but  not  invariably,  present. 
Loss  of  flesh  and  of  strength  is  noted 
from  the  first,  but  it  seems  to  bear  no 
direct  relation  to  the  extent  of  lung 
involved.  There  is  often  developed  a 
peculiar  pallor  of  the  skin,  resembling 
that  of  pernicious  anaemia.  In  other 
cases  the  skin  is  cyanotic. 

In  some  patients  the  symptoms 
progress  steadily,  emaciation  becomes 
extreme,  and  death  results  from  ex- 
haustion or  from  secondary  involve- 
ment of  other  organs,  or  the  patient 
„    „,^    .    ,  .     .    ,     mav  pass   into   a  typhoid   state.      In 

tiG.  38. —  Physical  Signs  in  the  ■•      >■  •'  '■ 

earliest  stage  of  pulmonary  tu-  OtllCr  CaSCS  tllC  prOCCSS  Will  appar- 
barculosis :    diminished   e.xpan-  ^y  ,  c  j_-  vi  1 

,        entlv^  stop  for  a  time,  with  a  fjeneral 

sion ;      percussion      normal     or  j  i  '  o 

tympanitic :  breathing  weak  or  im[)rovement    of    all    tlic    symptoms. 

harsh  :     pleuritic    or    bronchial     ^-^  .  1  i  1        • 

rales.  Unce  quicsccnt,  the  tuberculosis  may 

never  again  extend,  and  a  permanent 
cure  may  thus  be  affected.  In  other  cases,  after  an  interval 
the  process  will  again  start  up  and  involve  fresh  areas  of 
the  lung,  with  a  return  of  the  old  symptoms.  In  still  other 
cases  intercurrent  attacks  of  bronchitis,  pleurisy,  or  pneu- 
monia occur  to  modify  the  course  of  the  disease. 

The  physical  signs  may  be  described  as  appearing  in 
three  stages  : 

I.  The  tubercles  are  scattered  at  one  apex;    there  is  a 


TUBERCULAR   DISEASES   OF  THE   LUNG. 


339 


localized  terminal  bronchitis  and  a  dry  pleurisy.  There  is 
diminished  expansion  at  the  apex.  The  percussion-note 
may  be  normal,  tympanitic,  or  slightly  dull.  Vocal  fremitus 
is  usually  unchanged.  Breathing  sounds  may  be  feeble  or 
harsh  and  puerile,  but  at  this  stage  no  tendency  toward 
bronchial  breathing  is  observed.  On  auscultation  crepitant 
and  subcrepitant  pleuritic  rales  and  fine  bronchial  rales  are 
heard,  affording  strong  presumptive  proof  of  pulmonary 
tuberculosis  when  localized  at  one  apex  (Fig.  38). 


Fig.  40. — Physical  signs  of  pulmonary 
tuberculosis  in  the  final  stages  :  a,  signs 
of  consolidation,  gurgles,  and  pleuritic 
rales  ;  b,  signs  of  consolidation  and  rales; 
c,  dull  tympany,  prolonged,  high-pitched 
expirations,  rales;  d,  tympany,  feeble 
breathing,  rales. 


Fig.  39- — Physical  signs  of  pulmonary 
tuberculosis  in  the  advanced  stage  :  a,  di- 
minished expansion,  dulness,  bronchial 
voice  and  breathing,  increased  vocal  fremi- 
tus; pleuritic  and  bronchial  rales;  b,  dull 
tympanitic  note,  prolonged  and  high- 
pitched  respiration,  bronchial  and  pleuritic 
rales;  c,  tympanitic  or  normal  note,  feeble 
or  harsh  breathing,  pleuritic  and  bronchial 
rales. 

2.  As  the  tubercles  grow  and  coalesce,  portions  of  lung 
— usually  one  or  both  apices — are  rendered  solid.  Over 
these  portions  the  note  becomes  dull,  the  expiratory  sound 
becomes  prolonged  and  high-pitched,  and  ultimately  bron- 
chial breathing  and  bronchophony  are  developed.  The 
physical  signs  noted  in  the  preceding  paragraph  spread  at 
the  periphery  of  the  lesion  (Fig.  39). 

3  When  small  cavities  begin  to  be  formed,  gurgles  make 
their  appearance.  The  cavities  are  rarely  large  enough  to 
yield  other  and  more  distinctive  signs,  although  a  number  of 
small  cavities  may  merge  into  one  large  antrum  over  which 


340        M.IXL'AL    OF    /•///•;    rK.ICf/CE    OF  MEDICIXE. 

can  be  obtained  a  tympanitic  or  a  "  cracked-pot  "  note  with 
broncho-cavernous  or  cavernous  breathing  (Fig.  40). 

The  diagnosis  of  puhnonar\'  tuberculosis  should  be  sus- 
pected in  every  case  of  dry  pleurisy  at  the  apex  or  of 
bronchitis  at  the  apex.  The  disease  should  be  suspected 
in  every  case  of  severe  recurrent  bronchitis  or  dry  pleu- 
risy, if  the  constitutional  symptoms  be  out  of  proportion 
to  the  apparent  lesion.  It  should  be  suspected  in  the  case 
of  an)'  patient  with  fever  and  rapid  pulse  without  apparent 
cause,  even  in  the  absence  of  definite  ]:)ulmonary  s\,'mptoms. 
The  positive  diagnosis,  however,  can  only  be  made  by  the 
finding  of  tubercle  bacilli  in  the  sputa. 

The  prognosis  of  rapidly-spreading  tuberculosis  is  bad. 
Under  proper  environment  the  disease  may  become  chronic 
or  may  even  become  quiescent. 

Treatment  of  all  tubercular  diseases  of  the  lung  will  be 
considered  later  (see  p.  356). 

Chronic  Pulmonakv  Tuberculosis. 

Chronic  pulmonary  tuberculosis  differs  from  the  acute 
form  in  the  chronicity  of  its  course  and  the  slow  reactive 
nature  of  the  secondary  inflammatory  processes.  Three 
distinct  clinical   groups   may  be  described  : 

I.  Miliary  tubercles  are  formed  at  one  apex  and  slowly 
spread  downward.  The  opposite  apex  is  next  involved  in 
like  manner.  When  the  disease  is  fully  developed  the 
tubercles  are  found  scattered  throughout  both  lungs.  The 
miliary  tubercles  run  a  very  inactive  course,  some  becoming 
cheesy,  while  others  undergo  fibroid  change  or  are  encapsu- 
lated. There  is  a  chronic  bronchitis,  at  first  limited  to  the 
apex,  later  becoming  general.  Bronchiectatic  cavities  may 
form,  but  they  are  of  rare  occurrence.  Dry  pleurisy, 
resulting  in  pleural  adhesions  and  thickening,  is  due  to  the 
irritation  of  tubercles  near  or  in  the  pulmonary  pleura,  and 
it  is  usually  best  marked  at  the  apex.  In  the  later  stages 
of  the  disease  the  tubercles  may  become  so  closely  aggre- 
gated as  to  cause  partial  or  complete  consolidation  of  por- 
tions of  the  lung,  especially  at  the  apices;  while  the  forma- 
tion of  small  cavities  occurs  in  the  most  advanced  cases. 


TUBERCULAR  DISEASES   OF   RlfR    /.UNi;.  34 r 

Symptoms  begin  insidiously.  The  first  complaint  may 
be  of  a  hacking  cough  with  scanty  expectoration,  due,  as 
proved  by  physical  examination,  to  a  localized  bronchitis  at 
one  apex.  In  other  cases  a  dry  pleurisy  at  one  apex  will 
cause  pain  to  be  the  initial  symptom.  Other  patients 
suffer  from  haemoptysis  while  in  apparently  robust  health. 
In  other  patients,  the  lesions  give  no  subjective  symptoms, 
and  the  presence  of  the  disease  is  only  discovered  by  a 
routine  examination  of  the  chest.  When  the  disease  has 
once  developed  there  is  a  cough,  usually  troublesome  and 
persistent.  It  may  be  dry  and  hacking  or  loose  in  character. 
Expectoration  is  scanty  at  first,  but  later  becomes  profuse, 
muco-purulent,  contains  bacilli,  and  frequently  is  tinged 
with  blood.  Haemopt}'ses  may  occur  from  time  to  time, 
but  they  are  rarely  profuse  during  the  early  stages  of  the 
disease. 

Dyspnoea  is  present  according  to  the  extent  of  lung  in- 
volved, the  bronchitis,  and  the  pleurisy.  At  first  noticed 
only  on  exertion,  it  may  subsequently  become  steady  and 
distressing.  Extension  of  the  pleurisy  is  marked  by  fever 
and  pain.  Rapid  pulse  is  almost  constant  throughout  the 
disease,  so  that  pulmonary  tuberculosis  should  be  suspected 
in  all  patients  whose  pulse  is  continually  rapid  without 
apparent  cause.  Increased  rapidity  of  the  pulse  and  some 
afternoon  rise  in  fever  are  caused  by  fresh  accessions  of 
tubercles  or  by  exacerbations  of  the  pleurisy  or  the  bron- 
chitis. 

The  patient  loses  flesh  and  strength,  becomes  anaemic, 
and  is  converted  to  a  semi-invalid.  Later  in  the  disease, 
when  small  cavities  form,  "  hectic  "  develops — the  afternoon 
fever,  bright  eyes,  flushed  cheeks,  night-sweats,  and  more 
rapid  emaciation. 

The  physical  signs  of  chronic  pulmonary  tuberculosis 
resemble  those  of  the  acute  form.  There  may  at  first  be  no 
physical  signs,  or  there  may  be  diminished  expansion,  tym- 
pany or  tympanitic  dulness,  with  feeble  or  harsh  breathing 
at  an  apex.  Auscultation  reveals  pleuritic  and  bronchial 
moist  rales.  In  other  cases  thickened  pleura  at  an  apex 
yields  dulness  and  diminished  voice  and  breathing.     Later 


342        .V.LVC.IL    OJ'   THE   rRACTICK    OF  MEDIC  I. \E. 

appear  the  si^rns  of  partial  or  complete  consolidation — 
dulness,  bronchial  voice  and  breathing,  and  increased  vocal 
fremitus  with  a  persistence  of  the  bronchial  and  pleuritic 
rales.  The  final  stage  of  small  cavities  is  accompanied  by 
gurgles,  more  rarely  b}'-  tympanitic  or  "  cracked-pot  "  per- 
cussion-note and  by  broncho-cavernous  or  cavernous  voice 
and  breathing. 

Course  of  the  Disease. — {(i)  In  some  patients  the  lesion 
begins  at  one  apex,  but  after  a  certain  time  does  not  pro- 
gress, and  the  patient  lives  for  years  without  further  trouble. 
The  tubercles  still  remain  in  the  apex  of  the  lung,  but  they 
become  encapsulated,  fibroid,  or  calcareous.  Many  of  these 
patients  suffer  so  little  from  their  disease  that  no  suspicion 
of  tuberculosis  is  entertained.  There  is  always  danger  that 
at  any  time  the  process  will  start  anew  or  be  the  cause  of 
an  acute  general  miliary  tuberculosis. 

{b)  In  other  patients  the  lesion  is  progressive  only  at  long 
intervals.  Exacerbations  of  the  lesion  are  most  apt  to 
occur  during  the  winter  months,  during  any  intercurrent 
pulmonary  disease,  or  whenever  the  general  health  is 
allowed  to  deteriorate.  Many  old  cases  of  tuberculosis  are 
thus  stirred  into  renewed  activity  by  epidemics  of  the 
"  grippc-"  So  a  great  many  patients  go  on  for  years,  each 
succeeding  exacerbation  becoming  more  and  more  .severe, 
until  finally  the  extension-process  becomes  continuous. 
Under  proper  environment,  however,  the  course  even  of 
these  patients  may  be  prolonged  and  the  progress  of  the 
disease  may  ultimately  be  checked. 

(<r)  In  other  patients  the  course  of  the  disease  is  continu- 
ous. Pulmonary  and  hectic  symptoms  become  increasingly 
pronounced,  and  death  finally  results  from  emaciation,  from 
acute  general  miliary  tuberculosis,  from  hemorrhage,  or 
from  secondary  tubercular  inflammations  of  the  larynx,  the 
intestines,  or  the  peritoneum. 

II.  Before  the  time  of  the  tubercular  infection  the  patient 
has  suffered  from  emphysema  and  chronic  bronchitis,  possi- 
bly with  the  addition  of  thickened  and  adherent  pleurae. 
Such  a  complex  pulmonary  condition  seems  to  afford  a 
fertile  soil  for  the  development  of  the  tubercle  bacilli,  and 


TUBERCULAR   DISEASES   OF   TJ/E   /JJNG.  343 

the  lesions  of  pulmonary  tuberculosis  become  combined 
with  the  pre-existing  morbid  changes.  The  patient  at  first 
complains  only  of  the  symptoms  of  the  original  disorders, 
but  is  evidently  more  seriously  sick  than  he  should  be  with 
emphysema  and  bronchitis  alone.  Gradually  the  more  char- 
acteristic symptoms  of  tuberculosis  appear,  and  the  regular 
physical  signs  are  obtained.  The  course  of  this  set  of 
clinical  cases  resembles  that  of  the  first  variety,  but  is  much 
more  serious,  and  recovery  can  hardly  be  expected. 

III.  The  third  set  of  cases  resembles  either  of  the  pre- 
ceding forms  except  that  there  is  added  an  interstitial 
pneumonia.  The  connective  tissue  may  be  arranged  around 
the  tubercles,  along  the  bronchi,  may  extend  inward  from 
the  pleura  in  broad  bands,  or  may  occur  diffusely,  ren- 
dering parts  of  the  lung  completely  solid  and  fibrous.  As 
the  result  of  the  interstitial  pneumonia  the  walls  of  the 
bronchi  become  weakened  and  bronchiectatic  cavities  are 
permitted.  By  suppuration  or  tubercular  ulceration  of  the 
walls  of  the  dilated  bronchi  the  bronchiectatic  cavities  are 
still  further  increased  in  size.  The  interstitial  pneumonia 
may  precede  or  follow  the  deposit  of  tubercles  in  the  lung. 

The  symptoms  are  more  severe  than  those  of  the  two 
previous  forms,  resembling  those  of  chronic  pulmonary 
phthisis.  The  bronchitis,  however,  is  more  extensive ;  the 
expectoration  is  more  abundant  and  may  be  significant  of 
bronchial  dilatation ;  the  dyspnoea  is  more  distressing. 
Hectic  is  present  in  the  majority  of  cases,  and  repeated 
small  haemoptyses  may  occur  from  the  suppurating  or 
ulcerating  mucous  membrane  lining  the  bronchiectatic 
cavities.  If  the  interstitial  tissue  be  abundant  there  will  be 
offered  resistance  to  the  flow  of  blood  through  the  lunes. 
with  hypertrophy  of  the  right  ventricle  and  the  symptoms 
of  its  dilatation  in  the  latter  stages  of  this  disease.  To  this 
form  of  "  pulmonary  tuberculosis "  the  term  "  fibroid 
phthisis  "  is  often  applied. 

The  prognosis  of  pulmonary  tuberculosis  is  generally 
better  than  that  of  phthisis.  The  association  of  emphy- 
sema or  of  interstitial  pneumonia  with  the  deposition  of 
tubercles  renders  the  prognosis  more  serious  than  that  of 


344        M-!Xi.iL    OF  THE   PRACTICE    OF  MEDICEVE. 

uncomplicated  tuberculosis,  not  only  because  the  lung  is 
further  disabled,  but  because  of  the  additional  danger  of 
failure  and  dilatation  of  the  right  ventricle. 

The  treatment  of  all  tubercular  inflammations  of  the 
lung  will  be  considered  later  (see  p.  356V 

Acute  Pulmonary  Phthisis. 

Synonyms. — Acute  consumption  ;  Galloping  consump- 
tion ;   Phthisis  florida. 

Acute  pulmonary  phthisis  is  a  much  more  complex  dis- 
ease than  tuberculosis,  because  other  inflammatory  changes 
are  mixed  with  the  tubercular  lesions  in  the  lungs.  Tuber- 
culosis means  tubercles  alone ;  phthisis  means  tuberculosis 
plus  lobar  pneumonia  or  broncho-pneumonia. 

Etiolog-y. — Phthisis  may  be  a  primary  disease  or  may 
follow  some  previous  tubercular  inflammation  of  the  lung. 
A  person  predisposed  to  tuberculosis  will  develop  phthisis 
when  exposed  to  the  cause  of  inflammation  of  the  lung 
with  infection  at  the  same  time  b)'  the  tubercle  bacilli. 

Pathology. — The  process  usually  starts  at  the  apex  of 
one  lung  and  involves  the  lobe  or  even  the  entire  lung.  In 
other  cases  the  process  may  be  more  evenly  distributed 
throughout  both  lungs.  The  affected  portions  of  the  lung 
are  consolidated  from  gray  or  red  hepatization  or  from 
yellozvish  nodules.  There  are  frequently  cavities.  The 
bronchi  are  inflamed  and  bronchiectasis  may  occur.  There 
is  fibrin  in  the  pulmonary  pleura. 

It  seems  better  to  describe  separately  (i)  the  yellowish 
nodules,  (2)  the  pneumonia,  (3)  the  lesions  in  the  bronchi, 
and  (4)  the  cavities. 

I.  The  ycllenvish  nodules  vary  in  size  from  that  of  the 
head  of  a  pin  to  that  of  a  goose-egg.  By  the  coalescence 
of  these  nodules  still  larger  nodules  may  be  formed.  These 
nodules  consist  of  tubercle-tissue  in  the  condition  of  coagu- 
lation-necrosis. The  tubercle-tissue  may  fill  the  air-spaces 
and  the  small  bronchi,  being  grouped  like  the  inflammatory 
products  of  lobar  pneumonia ;  or  it  may  be  grouped  in  the 
air-vesicles  around  a  bronchus  whose  wallis  infiltrated  with 
tubercle-tissue,  in  this  case  resembling  the  grouping  of  the 


TUBERCULAR   DISEASES   OF   TJfE    J.ING.  345 

inflammatory  products  of  broncho-pneumonia.  These 
nodules  are  practically  composed  of  dead  tissue,  and  can 
never  be  recovered  from.  They  may  undergo  softening 
and  form  large  cavities. 

2.  The  piieiunonia  surrounds  the  nodules  and  involves 
the  lung-tissue  between  them.  The  hepatization  may  be 
red  or  gray  in  color.  In  some  cases  the  pneumonia  prod- 
ucts fill  the  air-vesicles  of  a  lobe  or  of  the  greater  part  of  a 
lobe,  resembling  lobar  pneumonia.  In  other  cases  the 
grouping  is  that  of  a  broncho-pneumonia  :  the  pneumonic 
products  occur  in  patches,  each  one  of  which  consists  of 
a  bronchus  with  infiltrated  walls  surrounded  by  a  zone  of 
consolidated  air-cells.  By  the  possible  coalescence  of  these 
peribronchitic  patches  large  areas  of  lung  are  rendered  solid. 
The  products  of  either  form  of  pneumonia  are  perfectly 
capable  of  resolution,  so  that  the  lung  can  again  return  to  a 
healthy  condition. 

3.  The  bronchi  may  be  the  seat  of  a  catarrhal  inflam- 
mation, or  their  walls  may  be  infiltrated  by  the  products 
of  tubercular  or  non-tubercular  inflammation.  Infiltration 
of  the  bronchial  wall  weakens  it,  allowing  of  cylindrical 
or  sacculated  dilatation.  If  the  infiltration  be  tubercular, 
ulceration  of  the  bronchial  wall  may  occur,  still  further 
increasing  the  size  of  the  bronchiectatic  cavity. 

4.  Cavities  may  be  formed  in  several  ways  :  {a)  By  the 
breaking  down  of  tubercular  nodules ;  {h)  by  bronchial 
dilatation ;  {c)  by  ulceration  of  the  walls  of  the  bronchi. 

Grouping  of  the  Lesions. — Delafield  describes  three  dis- 
tinct types  of  phthisis,  having  the  same  clinical  history,  but 
differing  in  appearance  and  in  the  physical  signs : 

1.  One  or  more  lobes  are  completely  consolidated  by  the 
filling  of  the  air-spaces  and  the  small  bronchi  with  .epithe- 
lium, fibrin,  and  pus.  Scattered  throughout  the  consolida- 
tion are  tubercular  nodules.  The  pleura  is  coated  with 
fibrin.  This  form  of  phthisis  is  described  as  "  acute  pneu- 
monic phthisis"  or  "acute  tubercular  pneumonia." 

2.  There  is  a  general  catarrhal  bronchitis,  and  a  tuber- 
cular inflammation  of  the  walls  of  some  of  the  bronchi  and  of 


346        MAXLAL    OF  77/E   fA'AC'/VC/-:    OF  MEDJCfXE. 

small  zones  of  air-spaces  surrounding^  them.     This  form  of 
phthisis   is  spoken  of  as  "  tubercular  broncho-pneumonia." 

3.  The  third  type  resembles  the  preceding  form  except 
that  in  addition  to  the  tubercular  broncho-pneumonia  there 
are  large  or  small  areas  of  diffused  consolidation  due  to 
the  filling  of  the  air-spaces  with  fibrin,  pus,  and  epithelium. 

Cax'ities  and  bronchiectasis  may  occur  in  any  one  of  the 
preceding  types. 

The  symptoms  of  phthisis  begin  acutely  or  gradually. 
If  the  onset  be  sudden,  the  symptoms  resemble  those  of 
pneumonia.  There  is  a  chill  followed  by  fever,  pain  in  the 
side,  a  cough  with  mucous  or  muco-purulent  expectoration, 
and  much  prostration. 

The  differential  diagnosis  of  these  cases  from  pneumonia 
is  always  difficult,  and  during  the  first  days  of  the  disease 
it  may  be  absolutely  impossible.  Pneumonia,  however, 
defervesces  between  the  sixth  and  the  twelfth  day,  with  im- 
provement of  all  symptoms,  whereas  in  phthisis  the  patient's 
condition  becomes  aggravated,  night-sweats  appear,  and 
the  expectoration  is  more  purulent  and  profuse.  Even 
then  the  case  may  resemble  one  of  tardy  resolution.  In 
pneumonia  haemoptysis  does  not  occur ;  in  phthisis  it  may 
be  an  early  symptom.  The  fever  in  phthisis  is  more  remit- 
tent than  in  pneumonia.  Should  cavities  form  or  bacilli  be 
found  in  the  sputum,  the  differential  diagnosis  would  present 
no  difficulties. 

If  the  onset  be  gradual,  there  will  be  a  cough,  dry  at 
first,  later  becoming  moist  and  accompanied  by  a  muco- 
purulent expectoration  which  may  contain  blood.  Haemop- 
tysis in  considerable  amounts  may  occur.  There  is  a  fever 
of  from  100°  to  102°  F.  with  afternoon  exacerbations.  The 
breathing  is  rapid,  but  subjective  dyspnoea  is  seldom  dis- 
tressing. When  the  disease  is  developed  the  cough  becomes 
looser;  the  expectoration  becomes  more  abundant  and 
more  purulent  and  contains  the  bacilli.  Large  haemoptyses 
arise  from  ulcerated  arterial  branches  in  the  walls  of 
cavities ;  repeated  small  hemorrhages  arise  from  the  ulcer- 
ating walls  of  bronchiectatic  cavities. 

The   fever   is   usually   remittent — about    100°    F.    in    the 


TUBERCULAR   J)ISEASKS   OR    'J7/R    /.(/NC.  347 

morning,  with  an  afternoon  exacerbation  to  103°  or  104°  F. 
The  remissions  occur  regularly  in  the  early  morning  hours ; 
they  are  accompanied  by  profuse  cold  sweats,  especially 
about  the  head  and  the  neck.  During  the  exacerbation  of 
the  fever  the  cheeks  are  flushed,  the  eyes  are  bright,  and 
the  whole  demeanor  of  the  patient  is  cheerful  throughout. 
The  pulse  becomes  increasingly  rapid  and  feeble ;  the 
breathing  becomes  more  and  more  rapid,  and  it  may  be  so 
inefficient  that  cyanosis  becomes  marked,  but  there  is  rarely 
any  complaint  of  dyspnoea.  The  patient  rapidly  loses  flesh 
and  strength  and  becomes  anaemic. 

The  physical  signs  at  first  are  those  of  broncho-pneu- 
monia or  of  lobar  pneumonia.  Over  the  consolidated  por- 
tions of  the  lung  there  are  diminished  expansion,  dulness 
on  percussion,  bronchial  breathing  with  bronchophony,  and 
subcrepitant  and  crepitant  rales.  If  there  be  a  tubercular 
broncho-pneumonia  without  much  consolidation,  there  may 
be  only  sibilant  and  sonorous  breathing  with  bronchial  rales, 
or  small  areas  over  which  there  are  dulness  on  percussion, 
intensified  voice,  and  crepitant  and  subcrepitant  rales. 
When  cavities  form  there  is  obtained  tympanitic  dulness 
or  a  "  cracked-pot  "  or  even  an  amphoric  note  ;  the  breath- 
ing and  the  voice  become  cavernous,  and  gurgles  and  churn- 
ing rales  make  their  appearance.  In  cases  in  which  the 
cavities  are  full  of  secretion  there  may  be  flatness  and 
absence  of  voice  and  breathing,  but  moist  rales  of  all  kinds 
are  heard  with  both  inspiration  and  expiration. 

Course  of  the  Disease. — (i)  Some  patients  die  in  two 
or  three  weeks  in  a  typhoid  condition  or  from  exhaustion  or 
hemorrhage.  The  diagnosis  of  lobar  pneumonia  is  often 
made  in  these  cases.  (2)  In  other  patients  the  disease  is 
prolonged  for  several  months.  (3)  Some  patients  pass  into 
the  condition  of  chronic  phthisis.  (4)  In  a  small  minority 
recovery  may  occur ;  the  tubercular  products  are  encapsulated 
or  undergo  fibroid  change,  while  the  non-tubercular  prod- 
ucts undergo  resolution. 

The  prognosis  of  acute  phthisis  is  unfavorable.  Recovery 
is  rare,  but  in  a  large  number  of  patients  the  lesions  become 
chronic,  so  that  life  may  be  considerably  prolonged. 


34^        M.iXL'A/.    OF  THE  /'A'.ICJVCE    OF  MEDICTNE. 

The  treatment  of  acute  cases  resembles  that  of  pneu- 
monia ;  in  subacute  cases  the  treatment  is  that  of  chronic 
puhiionary  phthisis. 

Chronic  Pulmonakv  Phthisis. 

Etiology  and  Synonyms. — Chronic  phthisis  may  appear 
as  a  primary  form  of  disease  or  may  be  secondary  to  pulmo- 
nary tuberculosis  or  to  any  pre-existing  tubercular  disease 
of  the  lung.  The  chronic  form  may  follow  acute  phthisis  or 
may  be  chronic  from  the  start.  Synonyms :  Chronic  con- 
sumption ;  Chronic  ulcerative  phthisis. 

Patholog-y. — The  lesions  of  chronic  phthisis  resemble 
those  of  the  acute  form,  except  that  they  are  modified  by 
their  long  duration  and  that  there  is  added  an  interstitial 
pneumonia.  Separate  descriptions  ma)'  be  given  of  (i)  the 
tubercular  nodules,  (2)  the  pneumonia,  (3)  the  interstitial 
pneumonia,  (4)  the  changes  in  the  bronchi,  (5)  the  cavities, 
and  (6)  the  lesions  in  the  pleura. 

1.  The  tubercular  nodules  are  arranged  as  are  those  of 
acute  phthisis.  In  some  cases  the  air-spaces  are  filled  with 
tubercle-tissue ;  in  other  cases  peribronchitic  areas  of  tuber- 
cular consolidation  occur,  the  wall  of  the  central  bronchus 
being  infiltrated  with  tubercle-tissue.  The  tubercular 
nodules  may  undergo  coagulation-necrosis  or  may  break 
down,  forming  cavities.  In  favorable  cases  the  nodules 
undergo  fibroid  change  or  become  encapsulated  with  cheesy 
or  calcareous  centres. 

2.  The  products  of  p)i€uinonia  are  grouped  like  those  of 
the  lobar  form,  the  air-spaces  being  filled  with  fibrin,  pus, 
and  epithelium,  or  there  may  be  the  peribronchial  nodules 
of  a  broncho-pneumonia. 

3.  The  interstitial  pneumonia  develops  in  several  ways : 
{a)  There  may  be  areas  of  lung-tissue  converted  more  or 
less  completely  to  fibrous  masses.  The  walls  of  the  air- 
spaces are  thickened  ;  their  cavities  are  encroached  upon 
by  polypoid  outgrowths  of  connective  tissue,  and  they  may 
be  filled  with  epithelial  cells.  {B)  Bands  of  connective 
tissue  extend  along  the  bronchi,  the  blood-vessels,  and  the 
septa  between  the  lobules,     ic)  Bands  of  connective  tissue 


TUBERCULAR  DISEASES  OF  THE  LUNG.      Pi.atic  21. 


'""''****is?:;s^i; 


:> 


Tubercle  bacilli  in  the  sputvim,  first  colored  with  anilin-fuchsin  and  then  with  methylene- 
blue  ;   X  about  1000  (Vierordt). 


TUBERCULAR  DISEASES   OE   THE   LUNG.  349 

penetrate  the  lung,  extending  inward  from  a  thickened  and 
adherent  pleura. 

4.  The  bro)icJu  undergo  the  same  inflammatory  changes 
as  in  acute  phthisis  :  {a)  They  are  the  seat  of  a  chronic 
catarrhal  inflammation,  [b)  Their  walls  may  be  infiltrated 
by  the  products  of  a  tubercular  or  a  non-tubercular  in- 
flammation, and,  being  thus  weakened,  sacculated  bron- 
chial dilatation  will  result,  {c)  If  the  infiltration  be  tuber- 
cular, ulceration  of  the  bronchial  wall  will  further  increase 
the  size  of  the  bronchiectatic  cavity. 

5.  Cavities  are  formed — {a)  By  the  softening  and  break- 
ing down  of  areas  of  coagulation-necrosis ;  {b)  by  bronchi- 
ectasis ;  and  (r)  by  tubercular  ulceration  of  the  walls  of  the 
bronchi.  Cavities,  when  once  formed,  tend  to  enlarge,  and 
as  they  increase  in  size  they  touch  and  open  into  one  an- 
other. In  this  way  the  greater  part  of  a  lobe  may  be  con- 
verted to  a  single  large  cavity.  A  blood-vessel  is  the  last 
structure  to  be  ulcerated  in  the  formation  of  a  cavity.  An 
obliterating  endarteritis  usually  occurs,  converting  the  ves- 
sel to  a  fibrous  cord,  thus  preventing  hemorrhage  at  the 
time  of  its  erosion.  Should  this  conservative  process  not 
be  completed,  partial  erosion  of  the  arterial  wall  will  allow 
of  the  formation  of  a  little  aneurysm,  which  may  finally  rup- 
ture, causing  profuse  hemorrhage.  Conservative  and  heal- 
ing processes  may  occur  even  after  a  cavity  has  once  formed. 
The  wall  of  the  cavity  becomes  thick  and  fibrous,  and  the 
lining  may  be  smooth,  resembling  mucous  membrane. 
Healing  processes,  however,  do  not  occur  in  cavities  of 
any  size. 

6.  The  pleiij'a  over  the  involved  area  of  lung  is  regularly 
the  seat  of  a  chronic  inflammation,  resulting  in  thickening 
and  adhesions.  This  form  of  chronic  inflammation  is  really 
conservative,  as,  by  the  strengthening  of  the  pleura  by  con- 
nective tissue  the  risk  of  perforation  of  cavities  or  of  bacte- 
rial infection  of  the  pleura  is  minimized. 

The  lesions  of  chronic  phthisis  usually  begin  at  the  apex 
of  one  lung  and  extend  downward  to  involve  the  upper  lobe 
and  the  apex  of  the  lower  lobe.  The  opposite  apex  is  then 
regularly  affected. 


350        M.IXr.lL    OF  TJIE   rKAC7ICE    OF  MFJUC/XE. 

Complicating  and  secondary  lesions  will  be  considered 
under  the  heading  "  Complications." 

Symptoms. — The  mode  of  onset  is  varied  and  insidious. 

1.  The  disease  may  begin  with  dyspeptic  and  anaemic 
symptoms  not  readily  alleviated  by  treatment.  Amenor- 
rhoea  is  an  early  symptom  of  these  anaemic  patients. 

2.  There  may  be  a  gradual  loss  of  flesh  and  of  strength, 
with  a  slight  afternoon  rise  in  temperature. 

3.  The  symptoms  of  a  "  neglected  cold  "  may  precede 
other  symptoms.  Cases  of  recurring  or  of  persistent  bron- 
chitis, especially  in  a  young  person,  should  always  be  re- 
garded with  suspicion. 

4.  Chills  and  fever  due  to  tubercular  infection  may  be 
mistaken  for  those  of  malarial  origin. 

5.  The  disease  may  begin  with  a  laryngeal  cough  and 
huskiness  of  the  voice,  and  on  examination  either  a  ca- 
tarrhal or  a  tubercular  laryngitis  may  be  found,  or  the 
larynx  may  appear  simply  anemic. 

6.  Haemoptysis  may  be  the  initial  symptom,  preceding 
other  manifestations  of  the  disease  by  months  or  even  by 
years. 

7.  There  may  be  dry  pleurisy,  especially  at  an  apex  or  in 
the  scapular  region,  or  a  pleurisy  with  effusion  running  an 
acute  or  an  insidious  course.  According  to  Bowditch, 
phthisis  ultimately  develops  in  one-third  of  the  cases  of 
pleurisy  with  effusion.  A  double  pleurisy  with  effusion  is 
much  more  suggestive  of  tubercular  origin. 

Symptoms  of  the  Developed  Disease. —  i.  Piduionary  Symp- 
toms.— (rt)  Cough  is  an  early  and  almost  a  constant  symp- 
tom. Dry  and  hacking  at  first,  it  later  becomes  looser  and 
more  frequent.  It  may  be  so  distressing  as  to  prevent  sleep, 
and  sufficiently  severe  and  paroxysmal  to  provoke  vomiting 
and  thus  to  interfere  with  the  patient's  nutrition.  (/>)  The 
sputum  varies  in  amount  and  character  in  the  different  stages 
of  the  disease.  At  first  the  expectoration  is  mucous  and 
of  a  glairy  consistency,  presenting  nothing  suggestive  of 
tubercular  trouble.  Later  in  the  disease  the  sputum  becomes 
muco-purulcnt  and  contains  little  grayish  or  grayish-green 
lumps.     When  cavities  form  the  expectoration  is  more  pro- 


TUBERCULAR  DISEASES   OF   TJ/E   LUNG.  35  I 

fuse,  especially  in  the  morning  or  after  sleep,  is  more  puru- 
lent, and  finally  the  sputa  assume  the  nummular  form  of 
separate  solid  purulent  masses  which  sink  in  water.  The 
expectoration  of  phthisical  patients  has  usually  a  heavy 
sweetish  odor,  although  it  may  be  fetid.  In  cases  of  con- 
solidation without  much  bronchitis  the  sputum  may  not  be 
abundant  at  any  time.  Generally  the  quantity  of  the  spu- 
tum gives  a  fair  test  of  the  activity  of  the  disease.  Exam- 
ination of  the  sputum  for  tubercle  bacilli  should  always 
be  made  in  doubtful  cases.  The  bacilli  are  usually  present 
early  in  the  disease  ;  they  are  abundant  in  proportion  to 
the  intensity  of  the  tubercular  process.  A  diminished  number 
of  bacilli  affords  grounds  for  a  more  favorable  prognosis. 
The  presence  of  bacilli  in  the  sputum  is  an  infallible  proof 
of  the  existence  of  tuberculosis,  but  their  absence  does  not 
necessarily  exclude  the  disease.  Tuberculosis  can  be  ex- 
cluded only  after  repeated  examinations  of  the  sputa  show 
absence  of  the  bacilli. 

The  demonstration  of  elastic  fibres  in  the  expectoration 
only  proves  the  existence  of  some  destructive  pulmonary 
lesion,  the  fibres  being  found  in  tuberculosis,  gangrene,  and 
abscess  of  the  lung.  If  the  sputum  be  pressed  between 
two  thin  cover-glasses  and  held  against  a  black  ground,  the 
elastic  fibres  can  usually  be  recognized  with  the  naked  eye. 
From  the  appearance  of  the  elastic  fibres  it  can  be  told 
whether  they  are  derived  from  the  bronchi,  the  alveoli,  or 
the  blood-vessels. 

Hemorrhage  occurs  in  60  per  cent,  of  all  cases  of  chronic 
pulmonary  phthisis ;  it  may  appear  early  or  late  in  the  dis- 
ease. Large  early  hemorrhages  never  lead  to  phthisis,  as 
is  erroneously  supposed,  but  arise  from  a  small  undiscovered 
lesion.  The  small  early  hemorrhages  usually  arise  from 
the  congested  or  ulcerated  walls  of  the  bronchi,  and  the 
blood  is  admixed  with  sputum.  Large  late  hemorrhages  arise 
from  the  erosion  of  an  artery  or  from  a  ruptured  aneurysm 
of  an  artery  within  a  cavity ;  in  these  cases  the  blood  is  pro- 
fuse and  is  unmixed  with  sputum.  For  the  differential  diag- 
nosis of  haemoptysis  from  haematemesis  see  Pulmonary 
Hemorrhage. 


35-      .u.ixr.iL  or  the  PRAcriCE  of  medicine. 

Small  hemorrhages  from  congested  bronchi  may  reHeve 
congestion  and  may  be  followed  b\'  a  feeling  of  general  im- 
provement. Large  hemorrhages  are  often  fatal,  either  from 
the  exhaustion  ami  anaemia  induced  by  them,  or  by  reason 
of  the  hemorrhage  itself,  or  because  blood  is  aspirated  into 
the  bronchi  of  the  other  lung,  causing  aspln-xia  or  septic 
pneumonia. 

Pai)i  may  be  a  distressing  symptom  or  it  may  be  absent 
entirely.  When  present  it  is  due  either  to  the  pleurisy,  to 
the  muscular  strain  of  coughing,  or  to  intercurrent  intercostal 
neuralgia. 

Tenderness  is  often  elicited  by  percussing  over  the  locality 
of  a  dry  pleuris)'. 

Dyspncca  on  exertion  increases  with  the  extension  of  the 
disease  and  with  the  exacerbations  of  the  bronchitis.  Con- 
stant dyspnoea  usually  indicates  excessive  involvement  of 
both  lungs  or  points  to  some  pleural  complication,  h^xtreme 
dyspncea  with  cyanosis  is  practically  unknown  in  uncom- 
plicated cases.  Pain  and  sudden  urgent  dyspnoea  suggest 
pneumothorax. 

Constitntional  Symptoms. — P'ever  usually  is  marked  in 
proportion  with  the  advance  of  the  lesion,  and  a  persistently 
normal  temperature  usually  means  that  the  disease  is  not 
progressing.  It  is  possible,  however,  for  consolidation  alone 
to  cause  no  fever,  the  febrile  condition  in  general  being  due 
to  the  bronchitis  and  to  the  suppuration  -in  the  cavities. 
The  fever  is  usually  remittent  or  even  intermittent,  the 
minimum  temperature  occurring  between  2  and  6  o'clock 
A.  M.,  the  maximum  being  noted  between  2  and  6  o'clock 
p.  M.  The  afternoon  rise  of  temperature  is  usually  accom- 
panied with  flushed  face,  brilliant  eyes,  and  a  "  hectic  flush." 
The  early  morning  remission  is  marked  by  profuse  cold 
night-sweats,  especially  about  the  head  and  the  neck.  The 
sweating  in  advanced  cases  also  recurs  during  the  day,  after 
sleeping.  When  extensive  suppurating  cavities  exist  the 
morning  temperature  may  be  subnormal.  A  continuous 
high  temperature  suggests  an  intercurrent  pneumonia.  The 
temperature  is  often  influenced  by  rest  and  by  good  nurs- 
ing, and  usually  declines  with  hospital  care.     The  tempera- 


TUBERCULAR   DISEASES   OE   TJ/E    LUNG.  353 

ture  becomes  also  less  marked  under  favorable  changes  of 
climate. 

The  pulse  is  rapid,  full,  and  compressible,  and  there  may 
be  capillary  pulsation  visible  under  the  finger-nails. 

The  patient  loses  flesh  and  strength  and  becomes  anaemic. 
These  changes  depend  upon  the  fever,  the  progress  of  the 
disease,  and  the  proper  feeding  and  treatment  of  the  patient. 
The  weight,  which  gives  a  good  index  of  the  progress  of 
the  disease,  should  always  be  considered  in  the  prognosis. 
It  is  possible,  however,  for  the  patient  to  retain  flesh, 
strength,  and  color  even  with  a  well-advanced  lesion. 

The  mental  state  is  peculiarly  cheerful,  and  even  mori- 
bund patients  are  firmly  confident  of  a  speedy  recovery. 

Menstruation  in  women  becomes  irregular  or  ceases 
altogether. 

Digestive  Symptoms. — Anorexia  may  be  a  well-marked 
symptom,  so  that  there  is  actual  loathing  for  all  food. 
Nausea  and  vomiting  may  appear  in  the  later  stages,  being 
due  to  paroxysms  of  coughing  or  to  dilatation  or  a  chronic 
catarrhal  inflammation  of  the  stomach.  As  a  rule,  how- 
ever, phthisical  patients  digest  well,  although  the  stomach 
lacks  its  normal  peristaltic  power  and  the  gastric  juice  is 
deficient  in  HCl. 

DiarrJicea  often  appears  in  the  later  stages  of  the  disease ; 
it  may  be  due  to  waxy  or  fatty  degeneration  of  the  liver,  to 
catarrhal  enteritis,  to  amyloid  degeneration,  or  to  tubercular 
ulcerations  of  the  intestine,  especially  of  the  large  bowel. 
Tubercular  ulceration  of  the  ileum  may  cause  no  diarrhoea, 
but  it  induces  an"  emaciation  that  cannot  otherwise  be 
accounted  for.  In  some  cases  no  lesion  is  found  post- 
mortem to  account  for  the  diarrhoea. 

Physical  Signs. —  i.  Signs  of  Early  Cases. — There  is 
usually  appreciated  by  palpation  a  diminished  respiratory 
expansion  at  one  apex ;  this  sign,  which  often  precedes 
all  other  physical  signs,  is  of  great  diagnostic  importance. 
The  percussion-note  over  and  under  the  clavicle  may  be 
normal  or  slightly  dull.  Breathing  (i)  may  be  simply 
feeble,  or  (2)  the  inspiration  may  be  inaudible,  while  the 
expiration    is    unduly    prolonged,    or    (3)    the    respiratory 

23 


354        M.l.yr.-IL    OF  THE   PRACTICE    OF  MEDICLXE. 

niuriiiur  may  be  harsh  and  rude  and  of  the  peculiar  wavy, 
jerky  character  s[)oken  of  as  "  cog-wheel  "  breathinij.  Fine 
moist, bronchial  rales  and  subcrepitant  pleuritic  rales  are  fre- 
quently heard  even  in  early  cases. 

2.  Signs  of  Evident  Consolidation. — The  deficienc}'  of 
local  chest-expansion  becomes  more  marked,  and  inspection 
may  show  some  sinking  of  the  infraclavicular  spaces.  The 
percussion-note  is  slightly  dull ;  the  breathing  and  the  voice 
approach  the  broncho-vesicular  (louder  and  higher  piched 
than  normal,  with  an  expiration  longer  and  higher  in  pitch 
than  inspiration).  Vocal  fremitus  is  usually  increa.sed 
unless  there  be  thickened  pleura.  These  physical  signs  are 
distinctive  when  obtained  at  the  left  apex,  but  are  nearly 
the  signs  normally  obtained  at  the  right  apex  ;  the  pres- 
ence of  bronchial  and  pleuritic  rales,  however,  not  being 
normal  to  either  apex,  may  make  the  diagnosis  evident. 
Later,  when  consolidation  becomes  more  marked,  the  dul- 
ness  becomes  more  pronounced,  the  breathing  and  the 
voice  become  bronchial,  vocal  fremitus  is  increased,  and 
the  bronchial  rales  become  coarser  and  more  numerous. 

3.  Signs  of  Cavities. — Numerous  scattered  cavities  with- 
out much  surrounding  consolidation  and  without  pleuritic 
thickening  may  yield  a  nearly  normal  percussion-note.  On 
auscultation,  however,  bronchial  breathing  and  gurgles  are 
heard.  Small  cavities  filled  with  secretion  may  give  rise  to 
marked  dulness  or  even  flatness.  Tympany  is  excited  over 
cavities  of  about  the  size  of  an  English  walnut.  The  tympan- 
itic quality  is  best  marked  when  the  patient's  mouth  is  open, 
constituting  "  Wintrich's  sign:"  A  "  cracked-pot  "  note  is 
obtained  by  firm,  sharp  percussion  over  superficial  cavities 
having  yielding  walls,  with  open  communication  with  a 
bronchus.  This  note  often  comes  and  goes,  is  reproduced 
by  coughing,  and  is  best  heard  when  the  percussor's  ear  is 
placed  directly  in  front  of  the  open  mouth  of  the  patient. 
It  must  be  remembered  that  a  "  cracked-pot"  note  may  be 
normally  heard  at  the  right  apex  in  some  children.  An 
amphoric  note  is  heard  by  percussing  large  cavities  with 
smooth  rigid  walls. 

The  breathing  over  cavities  may  be  bronchial,  broncho- 


TUBERCULAR   DISEASES   OE   I'lfE   LUNG.  355 

cavernous,  or  cavernous.  The  breathing  signs,  however, 
change  their  character  according  to  whether  the  cavity  is 
empty  or  is  filled  by  secretion.  A  distinctive  form  of  breath- 
ing heard  over  cavities  consists  of  a  respiratory  murmur, 
beginning  as  vesicular  and  suddenly  breaking  into  bron- 
chial. 

Gurgles  and  churning  sounds  are  heard  over  most 
cavities,  but  there  are  exceptions  in  which  the  cavities  are 
dry. 

It  should  never  be  forgotten  that  the  signs  of  a  cavity 
may  be  simulated  exactly  by  a  patch  of  consolidation  over 
a  large  bronchus,  so  that  the  diagnosis  of  a  cavity  should 
always  be  made  with  extreme  caution. 

Complications. — There  may  be  pleurisy  with  effusion  or 
empyema.  Perforation  of  the  pleura  over  a  softening  tuber- 
cular nodule  results  in  pneumothorax  or  of  pyo-pneumo- 
thorax.  There  may  be  tubercular  inflammation  of  other 
organs,  especially  meningitis,  tubercular  laryngitis,  and 
ulcerations  of  the  intestine.  The  kidneys  may  be  tuber- 
cular or  may  be  the  seat  of  amyloid  change.  Chronic 
diffuse  nephritis  may  develop.  The  liver  may  be  waxy, 
fatty,  or  the  seat  of  tubercular  deposits.  Tubercular  peri- 
tonitis may  be  present,  or  septic  peritonitis  may  result  from 
the  rupture  of  tubercular  intestinal  ulcerations.  Phthisis  at 
any  time  may  be  complicated  by  pulmonary  tuberculosis  or 
by  acute  general  miliary  tuberculosis.  Lobar  pneumonia  is 
not  uncommon  as  a  terminal  event.  There  may  be  developed 
in  phthisical  patients  a  form  of  insanity  resembling  that 
occurring  during  the  convalescence  from  acute  diseases. 
Peripheral  neuritis  is  occasionally  observed. 

The  prognosis  is  grave,  but  not  hopeless.  Favorable 
results  are  common  in  early  cases  properly  treated  by  change 
of  climate,  while  spontaneous  cures  are  not  infrequent,  even 
under  unfavorable  hygienic  surroundings.  The  prognosis 
is  dependent  upon  the  constitutional  vigor  and  the  finan- 
cial condition  of  the  patient,  and  the  rapidity  of  growth 
and  the  extent  of  the  lesions.  Repeated  haemoptyses  are 
unfavorable. 


356        MA.VUAL    OF  THE  PRACTICE    OF  MEDICINE. 

Treatment  of  Tubercvilosis  in  General. 

TheVe  arc  three  indications  for  treatment:  (i)  To  prevent 
tlie  spread  of  the  disease ;  (2)  to  arrest  the  disease ;  and 
(3)  to  reheve  symptoms. 

1.  PropJiylactic  Treat  incut. — {a)  For  the  Goural  Public. — 
The  sputa  of  all  tubercular  cases  should  be  collected  and 
destroyed.  The  patient  should  be  warned  not  to  spit  about 
the  house  or  in  the  street.  Portable  spit-cups  are  invented 
for  the  collection  of  the  sputa ;  or  handkerchiefs  may  be 
used  for  the  purpose  if  they  are  thoroughly  boiled,  after  use, 
in  a  receptacle  separate  from  that  for  the  other  clothes.  A 
phthisical  patient  should  sleep  alone,  and  separate  state- 
rooms on  steamships  should  be  provided  for  tubercular 
cases.  Rooms  infected  by  tubercular  sputa  should  be 
disinfected  thoroughly  before  they  are  again  occupied. 
There  should  be  governmental  inspection  of  dairies  and 
slaughter-houses,  and  tuberculosis  in  animals  should  be 
stamped  out  by  killing  the  infected  animals. 

Patients  with  tuberculosis  should  not  marry.  In  women 
with  a  suspected  tubercular  tendency  the  risk  of  develop- 
ing the  disease  is  largely  increased  b\'  childbearing. 

[b)  For  the  Individual. — A  child  born  of  tuberculous 
parents  should  receive  careful  prophylactic  treatment.  The 
mother  of  a  tuberculous  child  should  not  nurse  it  nor  sleep 
in  the  same  room  with  it.  The  child  should  enjoy  the 
recreations  of  an  outdoor  life,  and  studious  habits,  especially 
in  crowded  schools,  should  be  sacrificed  for  athletic  pur- 
suits. Sedentary  occupations  are  undesirable.  Nasal  ob- 
struction, enlarged  tonsils,  and  adenoid  disease,  if  present, 
should  receive  prompt  attention,  so  as  to  allow  of  the  fullest 
extent  of  breathing.  All  intercurrent  diseases  are  to  receive 
more  than  usual  attention,  and  the  general  health  is  to  be 
kept  at  the  highest  pitch  by  fresh  air,  sufficient  sleep,  proper 
food,  and  tonics  whenever  they  may  be  required. 

2.  To  arrest  the  disease  two  things  are  necessar}- — to  keep 
the  general  health  good,  and  to  prevent  complicating  inflam- 
mations. These  conditions  are  complied  with  by  {a)  climate, 
{b)  hygiene,  {c)  diet,  and  {d)  drugs. 


TUBERCULAR   DISEASES   OE  THE  LUNG.  357 

{a)  Suitable  change  of  climate  affords  the  best  chance  for 
permanent  recovery.  Usually,  however,  the  change  is  in- 
sisted on  too  late,  and  hopeless,  even  dying,  patients  are 
sent  on  long  journeys  away  from  friends  and  home  com- 
forts. There  is  no  one  climate  suitable  for  all  tuberculous 
patients,  and  in  the  selection  of  a  climate  good  judgment 
and  common  sense  must  be  employed.  Generally  speak- 
ing, the  requirements  are  a  pure  atmosphere,  an  equable 
temperature,  and  a  maximum  of  temperature.  As  to  the 
exact  choice,  much  depends  upon  the  patient.  Young  and 
robust  patients  with  early  lesions  do  best  usually  in  a  cold, 
bracing  climate,  where  they  can  lead  an  active  outdoor  life 
and  become  strong  and  muscular.  Such  cases  do  well  in 
the  Adirondacks  or  in  Colorado.  Those  who  are  unable  to 
take  physical  exercise  by  reason  of  age,  sex,  or  advanced 
pulmonary  lesions  do  best  in  a  warm,  dry,  equable  climate, 
where  they  can  sit  outdoors  and  keep  from  catching  cold 
without  being  obliged  to  exercise.  Such  a  climate  is  to  be 
found  in  Southern  California,  North  and  South  Carolina, 
Georgia,  Florida,  Mexico,  Egypt,  and  Algeria.  The  more 
unable  such  patients  are  to  exercise,  the  warmer  the  climate 
they  seem  to  need.  Some  patients  are  rendered  worse  in 
the  cool  climates  and  are  debilitated  by  warm  air.  Such 
patients  should  travel  from  place  to  place  until  they  find  a 
climate  in  which  they  improve  in  one  or  two  weeks.  Other 
patients  seem  to  do  best  by  a  variety  of  climates,  and  they 
improve  by  continually  travelling. 

{J})  Hygiene. — Tubercular  cases  require  a  maximum  of 
fresh  air  and  sunshine.  The  sleeping-room  should  be  airy 
and  sunny.  Exercise  in  the  open  air  should  be  graded  to 
the  strength  of  each  patient,  much  harm  being  done  by  con- 
scientious exercise  past  the  point  of  moderate  fatigue.  The 
skin  should  be  kept  open  by  skin-frictions  and  daily  baths. 
The  patient  should  avoid  exposure  to  inclement  weather, 
but  over-coddling  weakens  him  and  increases  his  liability 
to  catch  cold.  The  patient  should  wear  flannels  through- 
out the  year,  but  should  not  be  over-clothed,  as  the  danger 
of  catching  cold  is  thereby  increased. 

{c)   The  diet  should  be  simple,  wholesome,  and  abundant. 


35^        J/.7.\r.//.    OF   THE   PKACTICE    OF  MEDICIXE. 

The  rule  is  that  tubcrcuhii'  cases  should  be  over-fed.  In 
addition  to  the  ordinary  diet,  as  much  milk  and  cream  as 
possible  should  be  taken,  and  all  dyspeptic  s)-mptoms 
should  receive  proper  attention.  If  milk  and  cream  are  not 
well  borne,  cod-liver  oil  should  be  given  in  as  large  doses 
as  the  patient  will  tolerate.  Superalimentation  by  the 
stomach-tube  is  often  of  great  benefit.  Alcohol  with  meals 
may  be  allowed  if  it  agrees. 

{d)  Drugs. — A  large  number  of  specifics  are  lauded  every 
year,  but  each  one  fails  in  fulfilling  expectations.  There  is 
no  specific  treatment.  A  glycerin  extract  of  the  culture  of 
the  tubercle  bacilli  was  first  used  by  Koch,  and  it  was  found 
to  exert  a  specific  effect  on  tubercular  inflammations.  Injec- 
tions of  one  milligram  were  followed  by  intense  constitu- 
tional and  local  reaction,  and  cures  of  external  tuberculosis, 
such  as  lupus,  were  recorded.  In  internal  tuberculosis, 
however,  old  quiescent  lesions  were  stirred  into  activity, 
and  acute  miliary  tuberculosis  often  developed  from  a  local 
lesion.  Various  modifications  of  Koch's  lymph  have  been 
used,  but  they  should  be  used  with  extreme  caution.  At 
present  the  feeling  among  the  profession  is  strongly  against 
the  use  of  the  lymph,  but  modifications  and  improvements 
may  in  the  future  place  it  among  the  standard  list  of  specific 
drugs. 

Creosote,  which  has  been  gaining  steadily  in  favor,  is  one 
of  the  best  remedies  in  use.  It  may  be  given  in  4-minim 
doses  at  first,  gradually  increased  to  10  or  15  minims  three 
times  a  day.  It  may  be  given  with  compound  tincture  of 
gentian  or  with  glycerin  and  whiskey,  and  it  should  be 
diluted  largely  with  water  at  the  time  of  its  administration, 
or  it  may  be  given  in  capsules.  Only  the  pure  beechwood 
creosote  should  be  prescribed.  The  "  enteric  pill "  of 
Parke,  Davis  &  Co.  contains  creosote ;  it  is  not  dissolved 
until  it  reaches  the  small  intestine.  The  patient  may  wear 
continuously  a  perforated  zinc  inhaler  (Robinson's)  kept 
moistened  with  equal  parts  of  alcohol,  chloroform,  and 
creosote.  Creosote  may  also  be  given  by  the  rectum,  from 
5  to  20  drops  being  mixed  with  the  white  of  one  o.^^  and 
water  and  given  every  day.     Guaiacol  or  the  carbonate  of 


TUBERCULAR   DISEASES    OF    'J'JIE    JJJNG.  359 

creosote  may  be  used  in  substitution.  Iron,  strychnine, 
and  arsenic  are  useful  tonics  in  combination,  to  combat  the 
anaemia  and  to  build  up  the  general  strength.  The  hypo- 
phosphites  are  useful  tonics,  but  they  have  no  specific 
action. 

Injections  of  antiseptics  into  the  diseased  pulmonary 
tissues  have  been  advocated  warmly ;  they  are  not  com- 
monly employed,  however,  as  bad  results  have  occasionally 
followed  their  use. 

In  some  cases  the  inhalation  of  compressed  air  has  been 
of  great  service. 

3.  To  Relieve  Symptoms. — Fever,  as  a  rule,  is  best  treated 
by  change  of  climate  and  by  fresh  air.  When  the  tempera- 
ture is  high,  however,  patients  should  not  atteTnpt  much 
exercise,  and  frequently  they  do  better  when  put  to  bed  for 
a  few  days.  Sponging  with  cool  water  relieves  the  fever- 
ishness  and  makes  the  patient  comfortable,  but  other  more 
radical  measures  are  to  be  used  with  extreme  caution. 

For  the  sweating,  aromatic  sulphuric  acid  is  the  best  and 
the  simplest  remedy.  Sponging  the  body  with  vinegar  and 
water  upon  retiring  is  frequently  effective.  Zinc  oxide,  gr. 
ij,  with  ext.  hyoscyami,  gr.  iij,  in  pill  is  a  favorite  combina- 
tion, while  atropine  in  doses  of  gr.  -^^  at  night  is  fairly 
steady  in  its  effects.  Picrotoxin  (gr.  -g^)  may  be  used,  but 
with  extreme  caution.  Strychnine  is  often  of  use.  Cough, 
if  not  too  troublesome,  is  best  left  alone.  If  it  be  dry  or 
harassing,  opium  or  codeine  may  be  given  at  night  to  secure 
sleep.  Hydrocyanic  acid,  belladonna,  and  the  expectorants, 
in  combination  with  codeine,  often  relieve  this  troublesome 
symptom,  but  care  should  be  taken  that  the  stomach  be  not 
disturbed  by  nauseant  remedies.  If  the  cough  be  accom- 
panied with  profuse  expectoration,  the  expectorants  are  not 
indicated,  but  reliance  should  be  placed  upon  creosote,  tur- 
pentine and  its  derivatives,  and  the  mineral  acids. 

Pain  in  the  chest  is  to  be  treated  by  counter-irritation. 

For  the  treatment  of  haemoptysis  see  Pulmonary  Hem- 
orrhage. 

Diarrhoea  should  be  treated  on  general  principles,  but 
opium  in  some  form  has  almost  always  to  be  used. 


3C0       M.LVr.lL    OF   THE   PRACTICE    OF  MEDICEXE. 


4.  DISEASES  OF  THE  PLEURA. 

FIBRINOUS    OR   DRY     PLEURISY;    PLASTIC 
PLEURISY. 

Etiology. — Tliis  form  of  pleurisy  may  be  primary  or  sec- 
ondar}^  The  primary  form  ma\-  appear  to  be  due  to  expos- 
ure to  wet  and  cold,  but  modern  theories  regard  cold  merely 
as  a  predisposing  factor  to  bacterial  infection.  The  second- 
ary form  complicates  any  acute  or  chronic  pulmonary  disease 
involving  the  periphery  of  the  lung.  Thus,  pleurisy  occurs 
in  conjunction  with  pneumonia  with  abscess,  gangrene,  or 
cancer  of  the  lung,  and  with  hemorrhagic  infarctions. 
Occurring  with  pulmonary  tuberculosis  and  phthisis,  it  ma}' 
be  the  earliest  indication  of  tubercular  disease,  and  many 
cases  of  so-called  "primary  pleurisy"  owe  their  origin  to  a 
small  undisco\"ered  tubercular  lesion  in  the  lung  that  may 
finally  develop  and  give  rise  to  symptoms. 

Pleurisy  may  be  secondary  to  inflammation  of  organs 
other  than  the  lungs.  Thus,  pleurisy  may  arise  from  caries 
of  the  ribs  or  of  the  vertebrae,  from  perforation  of  an  oeso- 
phageal cancer,  from  tubercular  disease  of  the  bronchial 
glands,  from  pericarditis,  or  from  peritonitis.  Cases  follow- 
ing erysipelas  of  the  chest-wall  are  not  infrequent. 

Patients  with  gout  and  with  Bright's  disease  are  more 
subject  to  pleurisy  than  are  others.  A  pleurisy  develops 
during  the  course  of  acute  rheumatism,  the  pleura  being 
involved,  as  are  other  fibro-serous  membranes,  as  one  of 
the  regular  manifestations  of  the  disease.  The  belief  is 
gaining  ground  that  pleurisy,  after  all,  results  from  the  action 
of  various  micro-organisms,  the  most  common  of  which  are 
the  streptococcus  pyogenes,  the  pneumococcus,  and  the 
bacillus  tuberculosis.  Probably  there  are  man)' other  micro- 
organisms capable  of  causing  the  disease,  and  further  bac- 
terial examinations  are  desirable  to  enable  cases  of  pleurisy 
to  be  grouped  according  to  their  microbic  cause. 

Pathology. — The  pleura  becomes  congested,  dr\',  and  loses 
its  normal  lustre.     P'ibrin  and  serum  infiltrate  the  thickness 


FUiR/NOUS    OK   DRV  I'LEUKISY.  361 

of  the  pleura  and  make  their  way  to  the  free  surface,  so  that 
the  pleura  is  coated  with  a  layer  of  lymph  of  variable  thick- 
ness. The  exudate  may  be  shaggy  in  appearance  or  may 
be  thick  and  stratified.  Microscopicall}^,  the  fibrinous  exu- 
date consists  of  fibrin,  leucocytes,  red  blood-cells,  and 
serum.  The  serum,  however,  is  but  slight  in  amount  and 
undergoes  rapid  absorption.  Subsequently  the  exudate 
becomes  absorbed  or  becomes  organized  into  connective 
tissue,  so  that  the  pleura  is  thickened  and  adherent  to  the 
opposing  pleural  surface. 

Dry  pleurisy  usually  begins  in  the  pulmonary  pleura  and 
is  limited  to  a  small  area.  The  opposing  pleural  surface 
usually  is  involved  secondarily. 

Symptoms, — The  symptoms  of  secondary  pleurisy  are 
often  masked  by  those  of  the  primary  disease.  Pain  in 
the  side  and  the  friction  rale  are  the  only  characteristic 
symptoms. 

In  primary  cases  the  attack  may  begin  with  a  chill  and 
with  fever  rarely  over  102*^  F.  The  pain,  which  is  sticking 
or  stabbing  in  character,  is  referred  to  the  site  of  the  pleu- 
risy. The  pain  is  rendered  worse  by  deep  breathing  or  by 
coughing.  There  may  be  tenderness  in  the  intercostal 
spaces  over  the  lesion.  The  breathing  is  rapid  and  shallow, 
and  there  may  be  a  dry,  painful  cough  which  is  of  reflex 
origin.  In  mild  cases  a  stitch  in  the  side  on  deep  breathing 
may  be  the  only  symptom. 

Physical  Signs. — The  characteristic  physical  sign  of  dry 
pleurisy  is  the  pleural  friction  sound,  which  may  be  crepi- 
tant or  subcrepitant  or  which  may  resemble  a  moist  mucous 
rale.  The  crepitant  rale  is  a  fine  dry  crackle  or  shower  of 
crackles  heard  at  the  end  of  inspiration  only ;  it  arises  only 
in  the  pleura.  A  subcrepitant  rale  is  a  fine,  moist,  sticky 
sound,  heard  with  inspiration,  with  expiration,  or  with 
both.  Mucoid  rales  may  arise  from  the  rubbing  together 
of  surfaces  covered  with  very  moist  lymph ;  they  may  ex- 
actly simulate  the  bronchial  rales. 

The  differential  diagnosis  between  pleural  and  bronchial 
rales  is  as  follows : 


?62      j/.i.vr.iL  OF  THE  pkact/ce  of  medicine. 


Pleuritic  Rahs. 
I.  May  be  of  the  crepitant  variety. 
?.  Sound   superficial,  tiirectly  umler 
the  ear. 

3.  Fairly  constant. 

4.  Not  influenced  by  coughing. 

5.  Over  local  area,  which  does  not 
alter  its  position. 

6.  AH  of  one  variety. 


Bronchial  RRles. 

1.  Never  the  crepitant  variety. 

2.  Sound  "  deep  in." 

3.  Very  inconstant. 

4.  Influenced  by  coughing. 

5.  May  be  over  large   areas  or  in 
shifting  areas. 

6.  Usually  assorted  rales  of  all  kinds. 


The  occurrence  and  diagnosis  of  the  pleuro-pericardial 
friction  sound  has  been  described  under  Pericarditis  (p.  173). 

The  absence  of  pleuritic  rales  does  not  necessarily  ex- 
clude pleurisy,  as  the  rales  may  come  and  go,  may  only 
appear  on  deep  breathing,  and  may,  moreover,  arise  at  areas 
which  are  deeply  seated,  as  in  diaphragmatic  or  mediastinal 
pleurisy. 

The  duration  of  the  disease  is  from  three  to  ten  days. 

The  prognosis  of  the  attack  itself  is  good,  but  a  broader 
view  must  be  taken  than  that  of  mere  temporary  recovery. 
The  cause  and  the  significance  of  the  pleurisy  and  the 
sequelje  that  may  result  from  a  thickened  and  adherent 
pleura  must  be  considered. 

Treatment. — During  the  attack  the  patient  should  be 
kept  quiet,  but  need  not  necessarily  be  confined  to  the  bed, 
or  even  to  the  house,  unless  the  symptoms  be  severe. 
Counter-irritation  by  cupping,  by  iodine,  or  by  blisters  often 
diminishes  the  pain  and  checks  the  spread  of  the  inflamma- 
tion. Hot  poultices  are  not  so  efficient  as  ice-bags  applied 
locally.  In  all  cases  a  brisk  purgative  should  be  given  at 
the  start,  preferably  calomel  or  magnesium  sulphate.  For 
the  pain  morphine  may  be  given,  and  the  chest  may  be 
strapped  with  adhesive  plaster  as  for  fractured  rib,  to  dimin- 
ish the  friction  between  the  inflamed  pleural  surfaces.  In 
rheumatic  cases  salicylic  acid  or  its  derivatives  should  be 
given  in  full  doses,  as  for  acute  articular  rheumatism. 

PLEURISY  ^WITH  EFFUSION. 
Etiology  and  Synonym. — The  etiology  of  sero-fibrinous 
pleurisy  is  the  same  as  that  of  the  plastic  form.     The  former 
seems,  however,  to  be  due  to  a  severer  form  of  bacterial  infec- 


PLEURISY   IVI'J'II  EFFUSION.  363 

tion.  Pulmonary  tubercular  disease  follows,  in  time,  one- 
third  of  the  so-called  "  primary  "  cases.  Synonym  :  Sero- 
fibrinous pleurisy. 

The  pathology  of  the  sero-fibrinous  is  the  same  as  that 
of  the  plastic  form,  except  that  there  is  added  an  excessive 
exudation  of  serum;  moreover,  the  inflammation  involves  a 
larger  area  than  in  dry  pleurisy.  The  exuded  fluid  is  of  a 
composition  resembling  that  of  blood-serum  ;  its  color  is 
citron-yellow,  and  it  may  be  clear,  or  somewhat  turbid  from 
flocculi  of  fibrin  or  from  leucocytes  and  desquamated  cells 
from  the  pleural  surface.  Blood  may  be  present  from  rup- 
ture of  fine  blood-vessels  or  in  the  case  of  cachectic  and 
debilitated  subjects.  The  amount  of  the  exudation  varies 
greatly.  An  amount  under  300  cubic  centimeters  does  not 
give  rise  to  physical  signs  in  an  adult.  From  one  to  two 
pints  is  the  usual  quantity,  but  eight  to  ten  pints  may  be 
exuded.  The  exudation  sinks  to  the  dependent  portions  of 
the  pleural  sac  unless  encapsulated  by  previously  existing 
adhesions — a  somewhat  rare  occurrence  in  sero-fibrinous 
pleurisy.  The  fluid  in  the  pleural  sac  rarely  changes  its 
level  with  any  change  in  the  position  of  the  patient,  being 
practically  encapsulated  by  fibrinous  adhesions  between  the 
lung  above  and  the  costal  pleura.  The  upper  level  does 
not  follow  the  ordinary  laws  of  water-level,  but  follows  a 
curve  to  which  the  name  of  "  Garland's   S-curve  "  is  given. 

Mechanical  EflFects  of  the  EflEusion. — The  lung  floats 
upward,  its  base  resting  on  the  fluid.  As  the  fluid  takes  the 
place  of  the  lung  in  the  pleural  vacuum,  the  lung  is  free  to 
shrink,  from  its  own  elastic  retraction,  until  the  pleural  sac  is 
two-thirds  full  of  fluid ;  when  this  point  is  reached  the  lung 
is  in  a  condition  of  elastic  equilibrium.  Any  excess  of 
fluid  over  this  amount  exerts  a  direct  pressure  on  the  lung, 
so  that  in  extensive  effusions  the  lung  is  compressed,  form- 
ing a  dense,  airless,  carnified  mass  at  the  dome  of  the  pleu- 
ral cavity.  The  heart  is  bodily  displaced  to  the  opposite 
side,  but  it  undergoes  no  twisting  upon  its  axis,  so  that 
kinks  in  the  great  vessels  do  not  occur.  The  diaphragm 
is  sagged  downward,  and  in  right-sided  pleurisy  the  liver 
is  depressed.      The  intercostal  spaces  bulge,  especially  in 


364        M.-LVCAL    OF  TIJK   PRACTICE    OF  MKDICI.XF. 

children,  and  the  affected  side  measures  from  one-half  to 
one  inch  more  than  the  other  side. 

The  symptoms  are  iiijfaniiiiatory  and  viccliaiiical. 

1.  InJJaiiiDiatory  syviptoDis  may  occur  acuteh-  or  sub- 
acutely.  If  the  onset  be  sudden,  there  may  be  a  chill, 
which,  however,  is  never  so  severe  as  in  pneumonia.  The 
temperature  rises  to  from  101°  to  103°  F.,  attains  its  maxi- 
mum on  about  the  third  day,  and  slowly  subsides,  reaching 
the  normal  in  from  seven  to  ten  days.  The  temperature  is 
fairly  continuous,  not  remittent  as  in  empyema,  and  there  is 
no  definite  crisis.  Persistence  of  the  fever  after  two  weeks, 
or  a  temperature  higher  than  104°  F.  at  any  time,  suggests 
Qmpyema  or  tuberculosis.  Prostration  is  in  proportion  to 
the  severity  of  the  inflammation  and  the  fever.  The  pulse 
is  rapid  and  compressible.  Pain  is  marked  at  the  onset,  but 
it  becomes  less  marked  as  the  effusion  is  poured  out,  sep- 
arating the  opposing  inflamed  pleural  surfaces.  There  may 
be  a  reflex  cough  with  a  scanty  mucous  expectoration.  If 
the  onset  be  insidious,  the  inflammatory  symptoms  are  less 
marked.  The  chill  is  absent,  the  fever  is  rarely  over  ioi° 
or  102°  Y.,  and  prostration  is  so  slight  that  the  patient  is 
up  and  frequently  is  able  to  work. 

2.  Mechanical  symptoms  depend  upon  the  amount  of  the 
effusion  and  upon  the  rapidity  with  which  it  is  poured  out. 

Dyspnoea  results  from  the  pleuritic  pain  and  from  the 
diminished  expansion  of  the  lung.  It  may  be  present  only 
on  exertion,  or  it  may  be  so  extreme  as  to  be  most  distress- 
ing. The  more  rapidly  the  effusion  is  poured  out,  the  more 
marked  is  the  dyspnoea. 

The  position  of  the  patient  in  bed  is  often  suggestive. 
Before  the  effusion  is  poured  out  he  lies  upon  the  sound 
side,  so  as  not  to  press  the  inflamed  pleural  surfaces  together 
by  his  weight.  After  the  effusion  occurs  he  lies  upon  the 
affected  side,  so  that  the  weight  of  the  fluid  will  not  embar- 
rass the  action  of  the  heart  or  of  the  sound  lung. 

Cyanosis  is  likel)'  to  occur  in  cases  with  large  effusions, 
and  the  heart's  action  may  be  weak  and  irregular. 

The  physical  signs  may  be  described  as  occurring  before 


PLEURISY   WITH  EFFUSION. 


365 


effusion,  during  the  effusion,  and    after  absorption    of  the 
effusion. 

Before  the  effusion  the  friction  rales  of  dry  pleurisy  are 
present,  expansion  is  limited,  and  the  percussion-note  may 
be  slightly  dull. 

During  the  Effusion. — There  is  an  important  distinction 
to  be  made  between  the  physical  signs  of  moderate  and 
those  of  excessive  exudation. 

I.  The  signs  of  moderate  effusion  begin  to  appear  when 
the  exudation  reaches  ten  or  twelve  ounces  in  adults  or 
three  or* four  ounces  in  children. 

{a)  Beloiv  the  level  of  the  fluid  there  should  be  diminished 
expansion,  slight  bulging  of  the  intercostal  spaces,  espe- 
cially in  children,  and  an  in- 
creased girth  of  the  affected 
side.  The  percussion-note 
is  flat,  the  upper  limit  of  flat- 
ness describing  "  Garland's 
S-curve."  This  curve  begins 
low  in  the  back,  rises  to  its 
highest  point  in  the  axilla, 
and  then  sinks  with  a  slight 
descent  to  the  sternum.  The 
upper  line  of  flatness  is  rarely 
influenced  by  a  changed  position  of  the  patient.  In  left- 
sided  pleurisy  flatness  replaces  the  normal  tympany  of 
Traube's  semilunar  space.  Below  the  line  of  the  fluid 
the  voice  and  the  breathing  are  muffied  and  even  lost,  and 
vocal  fremitus  should  be  absent.  It  is  claimed  that  the 
whispered  voice  may  be  transmitted  through  serous,  but 
not  through  purulent,  effusions  (Baccelli's  sign). 

Exceptionally,  below  the  level,  voice  and  breathing  may 
persist,  though  distant  and  indistinct ;  pleuritic  rales  may 
be  heard  through  adhesions  persisting  below  the  level. 
In  children  soft  bronchial  voice  and  breathing  may  be 
heard,  even  if  there  be  no  compression  of  the  lung.  In 
some  cases,  especially  in  aged  subjects,  the  percussion- 
note  may  be  dull  or  dull-tympanitic  below  the  fluid.  Vocal 
fremitus  may  persist  below  the  level,  from  adhesions  extend- 


FiG.  41. — Garland's  S-curve. 


366        MAXLAL    OF   THE  PRACTICE    OF  MEDICIXE. 

ing  downward  through  the  cfTusion,  or  the  fremitus  may  be 
transmitted  alont;  the  cliest-wall  from  tlie  lung  above  or 
from  the  opposite  side. 

(/;)  At  the  level  of  the  flind  there  should  be  dulness  and 
pleuritic  rales.  Exceptionally,  a  bleating  of  the  voice 
(cegophony)  is  heard,  being  elicited  by  having  the  patient 
pronounce  the  words  "  want  "  or  "  plant."  CEgophony, 
however,  is  a  sign  of  rare  occurrence.  Pleural  rales  may 
be  absent  at  the  line  of  fluid. 

{c)  Above  the  level  of  the  fluid,  in  moderate  effusions,  the 
physical  signs  maj^  be  normal,  or  there  may  be  a  tympanitic 
percussion-note  WMth  feeble  breathing.  Tympany  in  these 
cases  is  due  to  relaxation  of  the  lung-tissue ;  it  is  most 
marked  under  the  clavicle,  constituting  "  Skoda's  sign."  In 
some  cases  in  children  the  note  under  the  clavicle  may  even 
be  of  the  "  cracked-pot "  order,  and  may  lead  to  the  erro- 
neous diagnosis  of  a  cavity,  especially  as  cavernous  breathing 
may  be  heard,  by  reason  of  a  large  bronchus  approaching 
the  chest-wall  owing  to  the  retraction  of  the  lung.  Both 
bronchial  and  pleural  rales  are  often  heard  over  the  retracted 
lung. 

(</)  Signs  of  Displaced  Viscera. — In  left-sided  pleurisy  the 
apex  beat  of  the  heart  may  be  under  the  sternum,  so  that 
it  cannot  be  appreciated,  or  in  more  abundant  effusion  it 
may  be  displaced  as  far  as  the  right  nipple.  In  right-sided 
pleurisy  the  apex  beat  may  be  as  far  to  the  left  as  the  mid- 
axilla.  Over  the  apex  of  such  a  displaced  heart  a  systolic 
murmur  may  be  heard.  In  right-sided  pleurisy  the  lower 
border  of  the  liver  is  felt  by  palpation  below  the  free  border 
of  the  ribs  in  the  mammary  line. 

2.  The  signs  of  excessive  exudation  differ  from  the  preced- 
ing physical  signs  in  that  the  lung  begins  to  be  actually 
compressed.  Over  the  compressed  lung  the  note  is  dull- 
tympanitic  or  dull,  the  breathing  and  the  voice  become 
broncho-vesicular  or  bronchial,  and  vocal  fremitus  is  in- 
creased. There  may  be  loud  bronchial  rales  of  a  gurgling 
quality.  As  the  lung  begins  to  be  compressed  "  Garland's 
S-curve  "  becomes  less  marked  until  finally  the  upper  limit 
of  the  flatness  is  a  straiijht  horizontal  line.     Below  the  level 


PLKURISY   IVrnf  EFFUSION.  ■}f)'J 

of  the  fluid  the  percussion-note  is  flat,  and  breathing  and 
voice  are  of  a  soft,  distant,  bronchial  character,  being  trans- 
mitted down  the  tense  chest-wall  from  the  compressed  lung 
above.  In  the  same  manner  vocal  fremitus  may  be  trans- 
mitted down  the  chest-wall  over  the  fluid,  although,  as  a 
rule,  vocal  fremitus  is  absent  in  these  cases.  The  chest  is 
usually  motionless  on  inspiration,  the  intercostal  spaces  are 
bulged  or  tense,  mensuration  shows  an  increased  growth  of 
from  one  to  one  and  a  half  inches,  and  the  disiDlacement  of 
the  heart  and  the  liver  becomes  evident. 

Patients  with  the  above  physical  signs  are  often  treated 
for  pneumonia,  but  a  mistake  in  diagnosis  should  not  occur, 
for,  if  doubt  exist,  the  aspirating-needle  should  be  used. 

As  the  effusion  becomes  absorbed  the  physical  signs  of  fluid 
disappear  and  breathing  is  heard  to  the  base  of  the  chest. 
The  friction  rale  usually  reappears.  Some  dulness  on  per- 
cussion and  feeble  breathing  with  friction  rales  persist  for 
months,  from  thickening  of  the  pleura. 

In  every  case  of  doubt  an  aspirating-needle  should  be  in- 
serted, with  the  strictest  antiseptic  precautions,  below  the 
supposed  level  of  the  fluid.  Fluid  may  not  appear  at  the 
first  introduction  of  the  needle,  should  its  calibre  be  blocked 
by  a  bit  of  fibrin.  The  use  of  the  aspirating-needle  not  only 
makes  positive  the  diagnosis  of  fluid,  but  it  determines  the 
character  of  the  fluid — whether  serous,  hemorrhagic,  or 
purulent. 

Course  of  Pleurisy  with  Effusion, —  i.  The  onset  may 
be  acute,  both  inflammatory  and  mechanical  symptoms  being 
pronounced.  Inflammatory  symptoms  subside  in  from 
seven  to  ten  days  ;  later  the  effusion  becomes  absorbed  or 
is  removed,  mechanical  symptoms  disappear,  and  the  patient 
recovers. 

2.  In  other  cases  the  inflammatory  symptoms  subside, 
but  the  fluid  remains  unabsorbed  and  mechanical  symptoms 
persist. 

3.  Other  cases  begin  as  pleurisy  with  effusion,  but  grad- 
ually septic  symptoms  develop.  The  fever  becomes  high 
and  remittent ;  there  are  erratic  chills  and  night-sweats  with 
rapid  emaciation.     The  aspirating-needle  shows  the  fluid  to 


368        .yAXi'AL    OF   THE  rRACriCE    OF  MEDICIXE. 

have  become  purulent  from  an  added  infection  by  pus  cocci, 
Tliese  cases,  howex-er,  are  rare. 

4.  The  onset  ma}'  be  insidious.  Inflammatory  symptoms 
are  not  marked,  but  mechanical  symptoms  ij^radually  in- 
crease. These  patients  are  the  ones  who  feel  "  run  down  " 
and  short  of  breath  on  exertion,  and  who  come  to  the  hos- 
pital with  a  chest  half  full  of  fluid. 

5.  There  may  be  a  double  pleurisy.  These  cases  are 
usually  of  tubercular  origin.  Their  course  is  persistent  and 
insidious,  and  pericarditis  is  a  frequent  complication. 

Sudden  death  is  a  rare  termination,  being  more  common 
with  the  severer  cases  of  pleurisy.  Post-mortem  examina- 
tion shows  in  some  cases  congestion  and  oedema  of  the 
lungs,  and  in  others  an  ante-mortem  heart-clot,  while  in 
other  cases  no  pathological  cause  can  be  found. 

Sequelse. — In  some  cases  the  pleura  returns  to  a  prac- 
tically normal  condition.  In  others  the  pleura  is  left  thick- 
ened and  adherent  and  may  lead  to  the  following  com- 
plaints : 

1.  Local  tenderness,  worse  on  exertion  or  in  damp 
weather. 

2.  Reflex  cough. 

3.  Pain  and  slight  dyspnoea  on  exertion. 

4.  There  may  be  developed  in  the  course  of  time — [a) 
chronic  bronchitis ;  {J?)  emphysema ;  (r)  interstitial  pneu- 
monia; {a)  chronic  pleurisy,  with  the  formation  of  new 
connective  tissue ;  or  {/)  recurring  attacks  of  pleurisy  with 
fibrin  or  with  effusion. 

The  heart  may  remain  fixed  in  its  abnormal  position  by 
adhesions,  or  it  may  ultimately  be  displaced  to  the  affected 
side  by  retraction  of  pleuritic  adhesions. 

The  prognosis  for  the  attack  itself  is  good.  Neglected 
cases  in  which  the  lung  has  been  compressed  may,  how- 
ever, do  badly.  The  ultimate  prognosis  should  consider 
the  underlying  cause  of  the  pleurisy  and  the  possibility  of 
sequelse  arising  from  pleural  thickening  and  from  adhesions. 

Treatment. — During  the  inflammatory  stage  the  patient 
should  be  put  to  bed  and  be  kept  on  a  light  diet.  Pain 
should  be  treated  by  counter-irritation,  strapping,   hot  or 


PLEURISY   WITH  EFFUSION.  369 

cold  applications  to  the  chest,  and,  if  necessary,  by  opium 
by  the  mouth  or  subcutancously.  Painful  cough  is  to  be 
relieved  by  sedatives.  In  rheumatic  cases  salicylates,  with 
or  without  potassium  iodide,  may  be  given. 

The  treatment  of  the  mechanical  symptoms  is  designed 
to  get  rid  of  the  effusion,  and  a  choice  of  two  methods  pre- 
sents itself: 

The  reduction  of  the  effusion  may  be  accomplished  by 
free  purgation  and  diuresis.  The  best  cathartic  for  the  pur- 
pose is  magnesium  sulphate  in  doses  of  from  i  to  i)4 
ounces,  given  every  second  morning,  an  hour  before  break- 
fast, in  a  concentrated  form.  The  choice  of  the  proper 
diuretic  is  simply  empirical :  one  after  another  should  be 
tried,  singly  or  in  combination,  until  the  desired  effect  is 
accomplished.  The  diet  should  be  concentrated,  and  only 
a  minimum  quantity  of  water  should  be  allowed. 

Withdrawal  of  the  effusion  by  aspiration  is  the  most  sat- 
isfactory treatment,  and  it  should  be  resorted  to  under  the 
following  conditions:  (i)  A  sudden  large  effusion  with 
dyspnoea  and  cyanosis.  (2)  A  large  effusion  with  marked 
mechanical  symptoms.  (3)  Should  the  physical  signs  of 
compression  of  the  lung  be  found.  Aspiration  in  these 
cases  should  be  done  without  delay.  (4)  Should  the  effu- 
sion be  uninfluenced  by  catharsis  and  diuretics.  Absorp- 
tion proceeds  better,  even  if  but  little  fluid  be  withdrawn. 
It  certainly  seems  wrong  to  waste  much  time  and  debili- 
tate the  patient  with  exhausting  treatment  when  so  safe  and 
efficient  a  means  of  relief  may  be  used. 

To  aspirate,  the  patient  should  be  semi-recumbent. 
Stimulants  should  be  at  hand,  and  the  strictest  asepsis 
should  be  employed.  The  needle  is  inserted  below  the 
level  of  the  fluid,  usually  in  the  eighth  space  in  the  axillary 
line,  and  the  fluid  is  withdrawn  slowly.  No  more  than  50 
ounces  should  be  withdrawn  at  any  one  time,  and  the  opera- 
tion should  be  stopped  at  once  if  severe  pain,  dyspnoea, 
faintness,  or  paroxysmal  cough  develop.  The  danger  of 
aspiration  is  sudden  heart  failure,  but  this  is  exceedingly  rare. 
After  aspiration  the  remaining  fluid  is  usually  absorbed,  but 

24 


370        MAXCAL    OF   THE   PRACTICE    OE  MEDIC  EXE. 

occasionall\-  the  fluid  reaccumulatcs,  and  it  must  be  removed 
by  a  second  or  even  a  third  aspiration. 

PURULENT   PLEURISY  (EMPYEMA). 

Etiolog-y. — Purulent  pleurisy  is  rej^ularly  due  to  the 
infection  of  the  pleural  cavity  b}'  some  micro-organism 
capable  of  exciting  supjiuration.  Infection  is  due  to  the 
following  bacteria  in  order  of  frequenc}^ :  Streptococci, 
pneumococcus,  tubercle  bacilli,  staphylococci,  Eberth's 
bacilli,  and  the  saprophytic  bacteria  of  gangrene.  These 
micro-organisms  may  infect  in  pure  cultures  or  in  combi- 
nations (mixed  infection). 

Infection  is  permitted  by — (i)  Penetrating  wounds  of  the 
chest-wall,  or  by  the  use  of  a  septic  aspirating-needle ; 
(2)  gangrene,  abscess,  or  septic  emboli  of  the  lung,  ruptured 
tubercular  cavities,  or  perforation  of  the  oesophagus  ;  (3)  in- 
fection through  the  diaphragm  following  abscess  of  the 
liver  or  peritonitis  ;  (4)  secondary  to  pneumonia  and  to 
some  acute  infectious  diseases,  as  scarlet  fever,  typhoid, 
measles,  whooping-cough,  and  "  grippe." 

Pathology. — The  lesion  of  purulent  pleurisy  is  the  same 
as  that  of  pleurisy  with  serous  effusion,  except  that  pus- 
cells  infiltrate  the  thickness  of  the  pleura  and  are  found  in 
the  effusion  in  varying  amounts.  The  exudate  may  be 
sero-pus,  or  thick  and  creamy,  or  of  a  greenish  or  yellowish 
color.  The  odor  is  usually  mawkish,  but  it  may  be  foul  or 
gangrenous.  A  peculiar  yeasty  odor  is  noticed  in  many 
cases  of  pneumococcus  infection.  The  effusion  is  more  apt 
to  be  sacculated  than  that  of  serous  exudation,  and  compres- 
sion of  the  lung  is  more  apt  to  occur.  Subsequent  changes 
may  occur  in  the  pleura,  in  the  effusion,  and  in  other  viscera. 

Changes  in  the  Plc7ira. —  i.  In  rare  cases,  especially  in 
children  and  in  pneumococcus  infection,  with  prompt 
removal  of  the  exudate  the  pleura  may  return  to  a  healthy 
condition. 

2.  The  pleura  may  become  thickened  and  adherent  after 
the  removal  of  the  fluid. 

3.  The  pleura  may  be  thickened;  its  surface  is  composed 


PURULENT  I'LIiURISY.  37  I 

of  granulation-tissue  secreting  pus,  constituting  a  pyogenic 
membrane. 

4.  In  the  pleura  may  be  deposited  the  salts  of  lime. 

5.  The  pleura  may  become  necrotic  in  places  and  slough. 
By  the  extension  of  the  necrotic  processes  the  pus  may  find 
its  way  through  the  chest-wall  (empyema  necessitatis),  or 
through  the  diaphragm,  or  it  may  rupture  into  the  lung  or 
the  pericardium. 

Changes  in  the  effusion  result  by  an  added  infection  of 
putrefactive  germs,  usually  those  of  gangrene  of  the  lung. 
The  effusion  becomes  foul  and  offensive,  and  gases  of 
decomposition  may  form,  constituting  pyo-pneumothorax. 
Small  purulent  effusions  may  become  inspissated  and  infil- 
trated with  lime-salts. 

Changes  in  other  viscera  are  those  changes  common  to  pro- 
longed suppuration.  There  may  be  amyloid  degeneration 
of  the  spleen,  the  liver,  and  the  kidneys,  or  chronic  diffuse 
nephritis. 

Symptoms  of  inflammatory  and  mechanical  origin  are 
present,  resembling  those  of  fibrino-serous  pleurisy,  but  in 
empyema  septic  symptoms  are  added,  consisting  of  erratic 
chills,  high  remittent  temperature,  cold  sweats,  prostration, 
diarrhoea,  emaciation,  and  the  development  of  a  septicemic 
or  typhoid  condition. 

1.  The  onset  may  be  sudden,  with  inflammatory  and 
mechanical  symptoms.  There  are  a  chill,  fever,  pain  in  the 
side,  prostration,  dyspnoea,  and  the  physical  signs  of  pleural 
effusion.  The  case  resembles  at  first  fibrino-serous  pleurisy, 
but  the  aspirating-needle  draws  pus.  Later,  septic  symp- 
toms develop. 

2.  The  onset  may  be  insidious.  Inflammatory  symptoms, 
such  as  initial  chill  and  fever,  are  not  marked,  but  mechani- 
cal and  septic  symptoms  slowly  develop.  The  patient  is 
indisposed  and  has  pain  in  the  side,  slight  fever,  and  dysp- 
noea. The  fever  becomes  higher  and  is  remittent.  Erratic 
chills,  cold  sweating,  and  prostration  become  marked. 

3.  If  empyema  follow  pneumonia,  there  is  usually  an 
attempt  at  crisis.  The  temperature,  however,  rises  again 
and  becomes  remittent,  dyspnoea  develops,  septic  symptoms 


3/2        .U.LVr.-lL    OF   THE   PRACTICE    OF  MEDICIXE. 

appear,  and  the  physical  signs  of  a  pleural  effusion  make 
their  appearance.  Chills,  however,  are  not  common  in  pure 
pneumococcus  infection  of  the  pleura. 

Course  of  the  Disease. —  i.  Some  patients  die  during  the 
acute  onset,  from  the  intensity  of  the  inflammation. 

2.  Septic.nemia  may  be  developed  in  early  cases,  especially 
if  the  effusion  undergoes  putrefactive  changes. 

3.  Some  patients  pass  into  a  hectic  condition  and  die  in 
several  months,  exhausted  or  in  the  t)-phoid  condition. 

4.  Death  may  result  from  the  primary  diseases,  as  phthisis, 
gangrene,  or  abscess  of  the  lung. 

5.  Death  may  result  from  perforation  into  the  pericar- 
dium or  the  peritoneum.  If  rupture  into  a  bronchus  occurs, 
pus  will  be  expectorated,  with  a  relief  of  all  the  symptoms. 
Owing  to  poor  drainage,  the  improvement  is  usually  tem- 
porary. In  rare  cases,  however,  spontaneous  cure  has  been 
effected. 

Aspiration  of  the  pus  into  the  bronchi  at  the  time  of  rup- 
ture may  cause  asphyxia  or  septic  broncho-pneumonia,  and 
pneumothorax  may  develop  by  air  entering  the  pleural  cav- 
ity through  the  bronchial  fistula. 

If  rupture  through  the  chest-wall  occurs,  the  opening  is 
usually  in  the  fifth  or  sixth  interspace  in  front.  Drainage 
is  usually  poor,  and  improvement  is  but  temporary.  Spon- 
taneous cure  may,  however,  result,  with  or  without  the  for- 
mation of  a  thoracic  fistula. 

6.  Small  circumscribed  empyemata  may  terminate  by 
gradual  absorption,  by  thickening  and  calcification  of  the 
pleura,  and  by  local  chest-retraction. 

The  physical  signs  are  in  the  main  those  of  fibrino-serous 
pleurisy.  Mention,  however,  should  be  made  of  a  few  addi- 
tional points : 

The  interspaces  are  apt  to  be  obliterated  more  than  in 
simple  pleurisy,  and  they  may  even  bulge.  There  may  be 
oedema  of  the  chest-wall.  Whispered  speech  is  not  usually 
transmitted  through  purulent  effusions. 

In  children  distinct  bronchial  breathing  may  be  heard 
over  a  large  purulent  effusion,  so  that  a  mistaken  diagnosis 
of  pneumonia  frequently  is  made. 


PURULENT  PLEURISY. 


373 


Pulsations  of  the  effusion  synchronous  with  the  cardiac 
systole  (pulsating  empyema)  is  sometimes  observed,  for  which 
no  satisfactory  explanation  can  be  offered.  Of  42  cases,  39 
occurred  on  the  left  side. 

Prognosis. — Empyema  is  a  very  serious  affection,  the 
severity  of  which  largely  depends  upon  the  particular 
micro-organism  to  which  it  is  due.  Infection  by  the  pneu- 
mococcus  is  regularly  less  severe  than  that  caused  by  the 
streptococci.  Cases  due  to  the  saprophytic  bacteria  of 
gangrene  afford  the  worst  prognosis.  The  prognosis  is 
better  in  children  than  in  adults,  in  cases  promptly  treated 
than  in  those  allowed  to  progress,  and  in  cases  with  slight 
sepsis.  The  prognosis  also  depends  upon  the  general  con- 
dition of  the  patient  and  the  nature  of  the  primary  disease. 


Fig.  42.  —Arrangement  of  bottles  for  forced  expiration. 

The  treatment  of  empyema  is  that  of  an  abscess  requir- 
ing incision  and  drainage.  Cases  due  to  simple  infection  by 
pneumonia,  especially  in  infants,  may  recover  after  aspiration, 
but,  as  a  general  rule  to  which  there  are  but  few  exceptions, 
aspiration  should  not  be  resorted  to  except  as  a  temporary 
measure.  Incision  and  drainage  should  be  insisted  upon, 
no  matter  how  desperate  the  patient's  condition  may  seem. 
The  details  of  the  operation  are  to  be  found  in  text-books 
on  surgery.  Irrigation  is  permissible  only  with  putrid  or 
gangrenous  empyema.  Chest-gymnastics  calculated  to  in- 
duce deep  inspiratory  efforts  are  of  value  in  convalescence. 
The  method  of  Ralston  James,  of  forced  expiratory  efforts, 


374        J/.I.VC'.^L    OF   THE   PRACTICE    OF  MEDICINE. 

is  to  be  advised  to  expand  the  retracted  lung.  By  the 
arrangement  of  the  water-bottles  shown  in  Figure  42,  water 
may  be  forced  from  one  bottle  into  the  other  by  blowing 
into  the  mouth-piece.  This  process  should  be  repeated  a 
number  of  times  daily. 

Should  the  lung  not  expand,  and  should  a  thoracic  fistula 
result  from  the  operation,  I^stlander's  operation  may  be  per- 
formed. This  operation  consists  in  the  resection  of  one  or 
more  inches  of  several  ribs  in  the  lateral  aspect  of  the  chest. 

CHRONIC    PLEURISY. 

Etiology  and  Synonyms. — A  thickened  and  adherent 
condition  of  the  pleura  may  result  from  acute  pleurisy, 
causing,  in  some  cases,  diminished  chest-expansion,  pain 
aggravated  by  deep  breathing  or  b}-  cold  and  damp  weather, 
and  possibly  a  reflex  cough.  Aside  from  these  symptoms, 
cases  are  met  with  in  which  the  pleura  is  the  seat  of  a  pro- 
gressive and  chronic  inflammation,  to  which  the  name 
"  chronic  pleurisy"  should  more  properly  be  applied.  Chronic 
pleurisy  may  follow  acute  pleurisy,  whether  plastic,  fibrino- 
serous,  or  purulent,  or  the  inflammation  may  be  chronic 
from  the  start.  Sytionyuis :  Chronic  adhesive  pleurisy; 
Pleurisy  with  the  production  o(  new  connective  tissue. 

Pathology. — Two  forms  of  the  disease  are  described  : 

1.  Chronic  Dry  Pleurisy. — The  lesion  is  usually  confined 
to  one  pleura,  but  it  may  be  bilateral.  The  pleura  is  thick- 
ened by  growth  of  connective  tissue,  so  that  it  may  exceed 
one-half  or  even  three-fourths  of  an  inch  in  thickness,  and  the 
opposing  pleural  surfaces  are  adherent.  This  form  of  pleu- 
risy occurs  most  extensively  after  empyema,  is  one  of  the 
regular  lesions  of  chronic  pulmonary  phthisis,  and  in  rare 
cases  may  appear  at  the  base  as  a  primary  disease. 

2.  Chronic  Plcnrisy  zvith  Effusion. — The  pleura  is  thick- 
ened ;  there  is  a  serous  effusion  which  in  many  cases  is  sac- 
culated, the  encapsulated  serum  being  encysted  by  thick- 
ened and  adherent  pleura.  In  cases  following  empyema 
there  may  be  collections  of  inspissated  pus  containing  lime- 
salts.  The  lung,  which  may  be  invested  with  thickened  pleura 
preventing  its  full  expansion,  maybe  the  seat  of  a  bronchitis 


CllJWNlC  I'LEUA'/SY.  375 

or  of  a  chronic  interstitial  pneumonia  with  or  without  bron- 
chiectasis.    The  heart  may  be  displaced  to  either  side. 

The  symptoms  at  first  are  shght.  There  is  a  pleuritic 
pain,  worse  on  deep  breathing  and  in  damp  weather,  fre- 
qently  associated  with  tenderness  in  the  overlying  intercostal 
spaces.  Dyspnoea  on  exertion  results  fi-om  diminished 
chest-expansion ;  it  is  more  marked  in  cases  with  .serous 
effusion.  There  may  be  a  cough  of  reflex  origin  or  due  to 
a  complicating  bronchitis.  The  patient  loses  flesh  and 
strength  and  becomes  anaemic.  These  symptoms  become 
more  and  more  marked  as  the  disease  progresses. 

Physical  Signs. — Inspection  shows  retraction  of  the 
chest-wall  and  diminished  expansion.  If  the  pleurisy  be 
dry,  there  will  be  dulness  or  flatness  according  to  the  thick- 
ness of  the  pleura  and  the  strength  of  the  percussion-blow. 
Breathing  and  voice-sounds  are  muffled,  distant,  or  absent 
altogether.  Vocal  fremitus  is  diminished  or  lost,  but  pleu- 
ritic fremitus  may  be  marked  on  forced  inspiration.  Auscul- 
tation reveals  pleuritic  rales,  creakings,  and  old  rubbing 
friction  sounds. 

If  there  be  fluid,  the  physical  signs  of  pleural  effusion  will 
be  present,  although  the  signs  are  often  obscured  by  those 
of  the  surrounding  thickened  pleura,  especially  if  the  effu- 
sion be  encapsulated.  There  may  be  added  the  physical 
signs  of  bronchitis,  bronchiectatic  cavities,  and  interstitial 
pneumonia. 

The  diagnosis  of  thickened  pleura  from  fluid  is  to  be 
made  with  certainty  only  by  the  use  of  the  aspirating-needle. 
If  the  pleura  be  thickened,  the  needle  is  felt  to  pass  through 
a  firm,  almost  cartilaginous  substance  which  gives  a  charac- 
teristic feeling  of  resistance.  The  diagnosis  of  chronic  pleu- 
risy from  new  growths  of  the  pleura  often  presents  great 
difficulties. 

The  course  of  the  disease  is  slow  and  steady,  extending 
over  years.  The  patient  is  finally  reduced  to  invalidism,  but 
death  almost  always  results  from  some  intercurrent  disease. 

Treatment  consists  (i)  in  building  up  the  general  health 
by  good  food,  proper  climate,  and  tonic  medication ;  (2)  in 
counter-irritation  by  iodine  or  by  blisters ;  (3)  by  exercises 


3/6        MAXr.lL    OF   THE    PRACTICE    OE  MEDIC  EXE. 

destined  to  increase  chest-expansion  ;  and  (4)  by  the  removal 
of  serous  accumulations  in  small  quantities  at  a  time. 

TUBERCULAR   PLEURISY. 

Etiolog-y. — The  association  of  pieuris)-,  both  plastic  and 
with  effusion,  and  pulmonary  tuberculosis  has  elsewhere 
been  described.  Besides  these  cases  the  pleura  may  be  the 
seat  of  a  tubercular  disease,  either  as  one  of  the  lesions  of 
acute  general  miliary  tuberculosis  or  as  a  localized  lesion 
which  may  be  primary  or  secondary  to  other  tubercular 
deposits,  especially  in  the  bronchial  glands. 

Pathology. — The  lesions  are  usually  confined  to  one  side, 
but  in  rare  instances  they  may  be  bilateral. 

1.  The  pleura  is  thickened  with  tubercular  nodules, 
cheesy  masses,  and  leucocytes,  and  miliary  tubercles  appear 
upon  the  free  surface.  The  appearance  of  the  pleura  and 
the  character  of  the  effusion  vary  in  different  cases. 

{a)  The  pleura  may  be  deeply  congested  and  be  studded 
with  miliary  tubercles.  There  is  a  hemorrhagic  serous 
exudation. 

{b)  The  pleura  is  studded  with  tubercles  and  covered  by 
fibrin.     There  is  a  fibrino-serous  effusion. 

{c)  The  pleura  is  thickened  with  caseous  and  softening 
tubercular  nodules,  its  surface  is  coated  with  fibrin,  pus,  and 
cheesy  matter,  and  it  may  present  tiibercular  ulcerations. 
The  effusion  is  purulent  and  contains  little  cheesy  masses 
and  shreds  of  the  pleural  tissue.  It  is  remarkable  that  in  a 
large  proportion  of  these  cases  neither  tubercle  bacilli  nor 
the  germs  of  suppuration  are  found  in  the  effusion  ;  but  in- 
oculation of  this  apparently  sterile  fluid  in  animals  is  fre- 
quently followed  by  the  development  of  tubercles. 

2.  There  may  be  a  tubercular  dry  pleurisy  thus  described 
by  Osier :  "  Both  parietal  and  costal  layers  are  greatly 
thickened — perhaps  from  two  to  three  millimeters  each — 
and  present  firm  fibroid  caseous  masses  and  small  tubercles, 
while  uniting  these  two  greatly  thickened  layers  is  a  red- 
dish-gray fibroid  tissue,  sometimes  infiltrated  with  serum. 
This  may  be  a  local  process  confined  to  one  pleura,  or  it 
may  be  in  both."      These  cases  are   frequently  combined 


PNE  UMO  7110  RAX.  377 

with  a  similar  condition  of  the  pericardium  and  the  peri- 
toneum. 

The  symptoms  of  tubercular  pleurisy  resemble  in  char- 
acter those  of  the  non-tubercular  forms,  but  run  a  slow, 
insidious  course.     Acute  cases  are  rare. 

Diagnosis  is  made  by  attention  to  the  following  particu- 
lars :  (i)  There  is  usually  some  antecedent  tubercular  his- 
tory, or  evidences  of  a  pre-existing  tubercular  disease. 
(2)  The  onset  of  the  pleurisy  is  insidious.  (3)  The  course 
of  the  disease  is  progressively  bad.  (4)  The  fluid  does  not 
disappear  with  medication :  it  persistently  reaccumulates 
after  aspiration.  (5)  Emaciation  and  prostration  are  out  of 
proportion  to  the  local  disease.  (6)  Aspiration  shows  a 
purulent  effusion  containing  cheesy  matter  in  which  tuber- 
cle bacilli  may  be  found,  or  the  serum  may  be  hemorrhagic. 
If  cancer  of  the  pleura  and  laceration  of  the  lung  by  the 
point  of  the  needle  be  excluded,  the  occurrence  of  a  hemor- 
rhagic serum  is  almost  diagnostic  of  tubercular  pleurisy. 

Duration. — Rare  acute  cases  may  terminate  in  two  weeks. 
The  usual  duration  is  from  three  to  six  months  or  even  longer. 

The  prognosis  is  regularly  fatal. 

Treatment  consists  in  building  up  the  general  health  by 
the  rules  laid  down  for  the  treatment  of  tuberculosis,  and  in 
the  withdrawal  of  the  fluid  by  aspiration  when  it  accumu- 
lates. Should  the  effusion  become  purulent,  the  case  should 
be  treated  as  one  of  empyema — by  incision  and  drainage. 

PNEUMOTHORAX ;    HYDRO-PNEUMOTHORAX ; 
PYO-PNEUMOTHORAX. 

Etiology. — Pneumothorax  arises — (i)  From  perforation 
of  the  chest-wall  following  penetrating  wounds,  incision  for 
the  drainage  of  empyema,  or  empyema  necessitatis.  (2) 
From  the  perforation  of  the  pulmonary  pleura  by  rupture 
of  the  lung  by  violence,  by  overstraining,  or  by  injur}'  from 
careless  aspiration;  or  there  may  be  rupture  of  emphy- 
sematous vesicles.  Air  may  dissect  down  the  peritracheal 
connective  tissue,  from  violent  coughing  attacks  following 
tracheotomy  whenever  the  tube  becomes  blocked,  and  may 
rupture  into  the  pleural  cavity.     One  fatal  case  of  the  writer's 


3/8        J/.l.Vr.l/.    ()/■   7V/£   PRACTICE    OF  MKDICLXE. 

occurred  in  this  way.  Rupture  of  a  tubercular  cavity  is  the 
direct  cause  ot  90  percent,  ofall  cases  of  pneumothorax.  Less 
coninion  are  the  cases  due  to  septic  broncho-pneumonia, 
abscess  or  gangrene  of  the  lung,  hemorrhagic  and  septic 
infarcts,  and  rupture  of  an  empyema  into  a  bronchus.  (3) 
From  the  perforation  of  other  organs,  as  from  cancer  of  the 
oesophagus,  the  stomach,  or  the  colon.  The  accident  may 
follow  perforation  through  the  diaphragm  of  a  subphrenic 
pyo-pneumothorax. 

Pathology. — When  air  enters,  the  pleural  vacuum  is  at 
once  destroyed,  and  the  lung  shrinks  by  reason  of  its  own 
elasticity,  the  heart  is  displaced  bodily  toward  the  opposite 
side,  and  the  liv^er  sags  downward,  exceeding  the  down- 
ward displacement  observed  in  pleural  effusion.  If  the  point 
of  perforation  remain  open,  the  intra-pleural  air  is  at  atmo- 
spheric pressure,  and  the  lung  is  not  compressed.  If  the 
orifice  of  rupture  be  valve-like  (ventilating  pneumothorax), 
air  can  enter  during  inspiration,  but  its  exit  during  expira- 
tion is  prevented,  so  that  the  intra-pleural  pressure  becomes 
raised  and  the  lung  becomes  compressed  and  carnified. 
The  point  of  rupture  may  be  large,  constituting  a  pleuro- 
bronchial  fistula,  especially  in  long-continued  cases,  or  it 
may  be  small,  baffling  detection  on  post-mortem  examina- 
tion. If  the  orifice  of  rupture  be  closed  by  a  contraction 
of  the  lung  or  by  a  deposit  of  fibrin,  the  intra-pleural  air  may 
be  at  any  degree  of  tension.  The  question  of  tension  is  of 
importance  in  the  understanding  of  the  ph}-sical  signs. 

In  rare  cases  the  entering  air  is  sterile,  and  a  simple  pneu- 
mothorax results;  usually,  however,  infection  and  infllam- 
mation  of  the  pleura  result  in  the  formation  of  a  serous 
effusion  (hydro-pneumothorax)  or  of  pus  (pyo-pneumo- 
thorax), the  latter  condition  being  far  the  more  common. 
The  effusion  sinks  to  the  dependent  portion  of  the  pleural 
cavity;  its  upper  level  is  a  straight  horizontal  line  (there 
being  no  Garland's  S-curve,  as  with  pleurisy  with  effusion), 
and  the  level  of  the  fluid  changes  regularly  with  the  vary- 
ing position  of  the  patient.  In  rare  instances  the  orifice  of 
perforation  is  surrounded  by  pleural  adhesions,  so  that  a 
localized  sacculated  pyo-pneumothorax  results. 


PNE  UMO  THORA  X.  379 

Symptoms. — The  symptoms  may  be  sudden  and  urgent 
or  may  be  latent  or  obscure. 

I.  If  pneumothorax  occur  in  a  fairly  healthy  patient,  the 
onset  is  sudden  and  alarming.  There  is  a  severe  pain  in 
the  side,  with  a  feeling  that  "  something  has  given  way." 
There  is  extreme  dyspnoea,  amounting  to  agonizing  air- 
hunger,  with  cyanosis  in  some  cases,  and  aphonia  "  for  want 
of  breath "  is  usually  observed.  Symptoms  of  surgical 
shock  rapidly  develop — lividity,  prostration,  cold,  clammy 
skin,  feeble  and  rapid  heart-action — and  death  may  result 
from  shock  within  a  few  hours.  Should  the  patient  survive, 
the  symptoms  of  shock  slowly  disappear.  Dyspnoea  con- 
tinues, with  rapid,  insufficient  breathing.  The  patient  sits 
up  with  the  body  inclined  to  the  affected  side.  There  are 
evidences  of  poor  circulation — lividity,  dropsy,  or  venous 
congestions.  Pain  in  the  side  continues,  and  the  symptoms 
of  pleural  effusion  make  their  appearance.  Death  finally 
results  from  exhaustion,  from  sepsis,  or  from  pre-existing 
disease. 

2.  If  pneumothorax  occur  in  a  person  much  debilitated 
by  phthisis  or  by  pulmonary  gangrene,  the  symptoms  are 
obscured.  Increased  dyspnoea  and  enfeebled  heart-action 
may  be  the  only  additional  symptoms.  In  some  cases  sud- 
den death  results.  In  rare  cases,  in  healthy  adults  with 
pneumothorax,  the  disease  runs  this  insidious  and  obscure 
course. 

3.  If  the  pneumothorax  be  due  to  rupture  of  pulmonary 
air-vessels  after  severe  straining  efforts,  the  air  is  usually 
absorbed,  but  inflammation  of  the  pleura  with  serous  effu- 
sion almost  regularly  results. 

Physical  Signs. — On  inspection  the  affected  side  is  en- 
larged and  motionless.  Vocal  fremitus  is  diminished  or  lost. 
The  percussion-note  depends  upon  the  tension  of  the  intra- 
pleural air.  If  the  air  be  at  low  tension,  the  note  will  be 
tympanitic  or  amphoric.  If  there  be  a  free  pleuro-bronchial 
fistula,  a  "  cracked-pot  "  note  may  be  obtained.  If  the  intra- 
pleural air  be  at  high  tension,  the  percussion-note  will  be 
dull-tympantic,  dull,  or  even  flat.  Percussion  over  a  pneu- 
mothorax frequently  gives  the  sensation  of  percussing  an 


380        .}/.-lXC:iL    OF   THE   PRACTICE    Oi    MEDIC IXE. 

air-cushion.  Flatness  is  obtained  over  the  effusion ;  the 
upper  Hniit  of  tlie  flatness  is  horizontal  and  changes  accord- 
ing to  the  position  of  the  patient. 

Breathing-  and  voice-sounds  may  be  feeble  and  distant, 
contrasting  with  the  exaggerated  breathing-sounds  o\'cr  the 
sound  side  ;  or  there  nia\'  be  a  distant  ins{:)irator\'  nuirmur 
of  amphoric  quality.  When  the  orifice  of  ru[)ture  admits 
air  freely,  voice  and  breathing  may  be  typically  amphoric. 

Should  the  lung  be  compressed,  there  will  be  bronchial 
voice  and  breathing  over  "the  carnified  lung,  heard  with  less 
distinctness  over  the  air.  The  Hippocratic  succussion  con- 
sists of  loud  splashing  sounds  heard  when  the  patient  is 
violently  shaken.  Similar  sounds  may  occur,  however, 
when  gas  and  fluid  are  shaken  in  a  distended  stomach. 
The  metallic  tinkle  consists  of  clear  tinkling  sounds  resem- 
bling those  produced  by  striking  a  pin  against  a  thin  glass 
tumbler.  The  "  penny-click  "  of  Trousseau  is  one  of  the 
most  characteristic  physical  signs  of  pneumothorax.  A  coin 
pressed  firmly  in  an  intercostal  space  in  front  is  tapped  with 
another  coin  while  the  auscultator  listens  at  the  back  of  the 
chest:  the  transmission  of  a  metallic  echoing  sound  is 
characteristic  of  a  large  air-cavity  ;  it  is  not,  however,  path- 
ognomonic of  pneumothorax. 

Aid  is  afforded  in  diagnosis  by  the  physical  signs  of  dis- 
placed liver  and  heart. 

The  diagnosis  is  usually  easy.  Mistakes  may  arise  by 
confusing  pneumothorax  with — {a)  Large  phthisical  cavities 
at  the  base  of  the  lung.  Here  the  penny-click  is  not  heard, 
succussion  is  rarely  obtained,  pleuritic  rales  are  heard  gen- 
erally over  the  area,  and  the  heart  and  the  liver  are  not  dis- 
placed. There  are,  moreover,  no  sudden  urgent  symptoms. 
{b)  Diaphragmatic  hernia  following  crush  or  injury,  (c)  Sub- 
phrenic pyo-pneumothorax. 

Prog-nosis. — But  few  cases  of  pneumothorax  recover. 
The  prognosis  depends  upon  the  cause,  the  septic  character 
of  the  infection  of  the  pleura,  the  general  condition  of  the 
patient,  the  presence  of  pre-existing  disease,  and  the  severity 
of  the  shock  and  the  reaction. 

Duration. — The  ordinarv  duration  of  the  disease  is  be- 


NEW  GROWTHS   OF   THE   PLEURA.  38 1 

tween  two  and  three  months.  Patients  may  die  in  shock 
in  a  few  hours,  while  in  rare  cases  the  disease  becomes 
chronic  and  extends  over  months  or  years. 

Treatment. — At  the  time  of  the  perforation  morphine  or 
chloroform  may  be  given  for  the  pain,  and  the  symptoms 
of  shock  may  be  treated  on  general  principles.  Where 
effusion  forms,  the  case  should  be  dealt  with  as  ordinary 
pleurisy  with  effusion  or  as  empyema — by  aspiration,  or 
incision  and  drainage.  In  pyo-pneumothorax  occurring  in 
advanced  phthisis  it  may  be  the  better  course  simply  to 
remove  the  pus  by  aspiration  rather  than  to  render  the  last 
days  of  the  patient  uncomfortable  by  a  surgical  operation. 

NE^W    GROWTHS    OP    THE    PLEURA. 

The  majority  of  new  growths  in  the  pleura  are  of  second- 
ary nature  and  complicate  tumors  of  the  lung  or  the  chest- 
wall,  the  pleura  being  directly  invaded  by  the  new  growth. 
Of  the  primary  new  growths  of  the  pleura,  endothelial 
carcinoma  is  the  most  important.  The  pleura  is  infiltrated 
and  studded  with  scattered  nodules,  or  the  cancer  may  be 
diffuse.  Pleurisy  is  developed  with  fibrino-serous  effusion, 
which  in  12  per  cent,  of  all  cases  is  of  a  hemorrhagic  char- 
acter. Secondary  metastatic  growths  may  occur  in  the 
lungs,  in  the  bronchial  glands,  or  in  distant  organs. 

The  symptoms  resemble  those  of  chronic  pleurisy  with 
effusion.  Pain,  however,  is  more  continuous  and  severe, 
and  there  may  be  exquisite  tenderness  in  the  intercostal 
spaces.  The  effusion  may  be  hemorrhagic,  and  cancerous 
cachexia  develops. 

Diagnosis. — Aid  in  diagnosis  may  be  afforded  by  the 
presence  of  malignant  tumors  elsewhere.  The  diagnosis 
in  the  earlier  stages  may  with  difficulty  be  made  from 
chronic  tubercular  pleurisy. 

The  physical  signs  are  those  of  thickened  pleura  with 
effusion. 

The  prognosis  is  invariably  fatal. 

The  treatment  is  simply  symptomatic.  If  sarcoma  of 
the  pleura  be  suspected,  hypodermic  injection  of  the  toxic 
products  of  erysipelas  germs  may  be  employed. 


.U.-i.vr.lL    O/--  THE   PRACTICE    OF  MEDIC  I XE. 


HYDROTHORAX. 

Etiology. — H\-drotliorax  occurs  with  dropsy  of  other 
organs,  with  nephritis,  with  diseases  of  the  heart,  and  with 
profound  ana.Mnia ;  it  ma}'  result  from  pressure  of  a  tumor 
upon  an  intrathoracic  vein. 

Pathology. — The  lesion  of  hydrothorax  consists  of  an 
accumulation  of  serum  in  the  pleural  cavity,  without  inflam- 
mation of  the  pleura  itself  In  the  cases  due  to  nephritis 
or  to  anaemia  the  lesion  is  usually  bilateral.  In  heart  dis- 
ease one  cavity  alone  is  involved  in  the  majority  of  instances  ; 
if  both  cavities  are  implicated,  however,  the  amount  of  the 
fluid  in  the  two  sides  is  not  equal.  Intrathoracic  pressure 
on  a  vein  regularly  results  in  unilateral  hydrothorax.  The 
fluid  is  simple  serum  without  inflammatory  ingredients,  the 
pleural  surfaces  are  normal,  and  the  amount  of  effusion  is 
rarely  excessive. 

The  symptoms  are  often  obscured  by  those  of  the  pri- 
mary disease.  Dyspnoea  is,  however,  increased  by  the  trans- 
udation, and  it  may  be  associated  with  cyanosis  and  great 
distress.     Pain  and  fever  are  absent. 

The  physical  signs  are  those  of  pleural  effusion.  The 
friction  rale  is  not  heard,  however,  and,  as  fibrinous  adhe- 
sions do  not  exist,  the  fluid  is  more  apt  to  change  its  level 
with  the  varying  position  of  the  patient  than  is  common  in 
fibrino-serous  pleurisy.  Compression  of  the  lung  rarely, 
if  ever,  occurs. 

The  prognosis  is  that  of  the  primary  disease. 

The  treatment  also  is  that  of  the  primary  disease.  The 
dropsies  are  to  be  treated  by  heart-stimulants,  diuretics,  and 
cathartics.  If  the  breathing  be  embarrassed  b>-  the  trans- 
udation, and  no  relief  follows  medicinal  measures,  repeated 
aspirations  are  to  be  resorted  to. 

HEMOTHORAX. 
Etiology. — Hemorrhage    into    the    pleural    cavity    may 
occur   from   rupture   of  an   aneurysm,  from  erosion   of  an 
intrathoracic  vessel,  or  from  injuries  resulting  in  fractures 
of  the  rib  or  in  laceration  of  the  lung. 


L  YMPIIADENITIS.  383 

Patholog-y. — The  blood  may  coagulate  and  be  absorbed 
if  not  too  excessive  in  amount.  If  infection  occurs,  there 
may  be  pleurisy  with  effusion  or  empyema. 

The  symptoms  are  those  of  hemorrhage — pallor,  dysp- 
noea, thready  pulse,  sighing  respirations,  and  restlessness, 
associated  with  pleuritic  pain  and  dyspnoea.  Symptoms  of 
pleurisy  with  effusion  or  of  empyema  may  develop  in  in- 
fected cases. 

The  physical  signs  are  those  of  pleural  effusion.  The 
friction  rale  is,  however,  absent. 

Prognosis. — A  large  haemothorax,  such  as  arises  from 
rupture  of  an  aneurysm,  is  rapidly  fatal.  Small  hemorrhages, 
especially  those  due  to  injury,  may  terminate  in  absorption 
and  recovery. 

The  treatment  is  that  of  acute  anaemia — by  transfusion, 
warmth  to  the  extremities,  and  small  doses  of  opium.  A 
small  haemothorax  is  best  left  alone.  If  the  clot  be  infected 
or  be  large  enough  to  interfere  with  respiration,  it  may  be 
evacuated  by  incision. 


5.   DISEASES  OF  THE  MEDIASTINUM. 

LYMPHADENITIS. 

Simple  lymphadenitis  follows  inflammations  of  the  lungs 
or  the  bronchi,  especially  in  children.  More  rarely  the  con- 
dition arises  in  the  course  of  some  infectious  diseases,  espe- 
cially typhoid  fever  and  diphtheria. 

The  lesion  consists  of  swelling  and  congestion  of  the 
gland,  resulting  either  in  resolution  or  in  enlargement. 
Suppuration  rarely  occurs.  Not  infrequently  the  glands 
become  secondarily  infected  by  the  tubercle  bacilli. 

The  adhesion  of  an  enlarged  gland  to  the  oesophagus 
may  result  in  a  traction-diverticulum. 

The  symptoms  are  rarely  ob.served.  In  some  cases  bron- 
chitis with  paroxysmal  cough  results  from  congestion  and 
irritation  of  the  neighboring  structures. 

Suppurative  lymphadenitis  may  follow  simple  or  tuber- 


384        MAXLAL    OJ-'    rilE    PRACTICE    OF  MEDJCJXE. 

cular  inflaniniation  of  tlic  glands.  The  pus  may  finally  be 
inspissated,  infiltrated  with  lime -salts,  and  encapsulated,  or 
it  may  rupture  into- the  bronchi  or  the  oesophagus. 

Tubercular  lymphadenitis  regularl)^  accompanies  tuber- 
cular lesions  in  the  lung.  In  other  cases  the  glands  filter- 
ing out  the  impurities  gaining  entrance  to  the  lungs  may 
primarily  be  infected.  The  tubercular  glands  may  attain  a 
large  size  and  may  cause  the  pressure-symptoms  of  a  medi- 
astinal tumor.  The  caseous  masses  may  become  inspis- 
sated and  encapsulated,  or  the\-  ma}-  rupture  into  neighbor- 
ing organs.  The  lungs,  the  pleura,  or  the  pericardium  may 
be  involved  secondarily  by  extension.  General  tuberculous 
infection  so  commonly  results,  especially  in  children,  that 
search  should  be  made  for  tubercular  glands  of  the  medias- 
tinum in  every  case  of  acute  miliary  tuberculosis  of  obscure 
origin. 

MEDIASTINAL    TUMORS. 

Of  520  cases  of  mediastinal  tumor  reported  by  Hare, 
cancer  occurred  in  134,  sarcoma  in  98,  and  lymphoma  in 
21.  Less  frequently  are  found  dermoid  and  hydatid  cysts, 
fibroma,  lipoma,  gumma,  and  enchondroma.  Growths 
formed  by  the  aggregation  of  tubercular  glands  and  aneur- 
ysms have  previously  been  described.  Cancer  may  be 
primary  or  secondary.  Sarcoma  is  more  apt  than  cancer 
to  be  primary,  men  are  more  frequently  affected  than  women, 
and  the  majority  of  cases  occur  between  the  twenty-fifth  and 
fortieth  years. 

The  symptoms  are  due  to  increasing  intrathoracic  pres- 
sure. Dyspnoea  is  the  most  marked  symptom  ;  it  is  due  to 
pressure  on  the  trachea,  the  recurrent  laryngeal  nerve,  the 
lungs,  or  the  bronchi.  In  the  latter  stages  of  the  disease 
orthopncea  is  usually  developed.  Cough  may  be  parox- 
ysmal, resembling  that  of  whooping-cough,  or  there  may  be 
a  brassy  cough  as  with  aneurysm.  Pressure  on  the  thoracic 
duct  occasions  rapid  emaciation.  Dysphagia  occurs  if  the 
oesophagus  be  compressed.  Compression  of  the  thoracic 
veins  results  in  cyanosis  of  the  chest,  the  arms,  the  head, 
and  the   neck,  and  in  extraordinary  attempts  to  establish 


Qidema  of  the  head  and  the  upper  extremities  with  sarcoma  of  the 
mediastinum. 


MEDIASTINAL    TUMORS.  385 

collateral  circulation.  Congestion  and  oedema  of  the  lung 
may  be  occasioned  by  pressure  on  the  pulmonary  vein. 
Pleural  effusion  is  apt  to  appear  either  by  an  involvement 
of  the  pleura  by  the  new  growth  or  from  pressure  of  the 
tumor  on  the  vena  azygos  or  on  one  of  the  intercostal  veins. 

Pain  is  not  as  common  with  tumor  as  with  aneurysm. 

Physical  Signs. — There  is  evident  dyspnoea.  Some 
valuable  aid  in  localizing  mediastinal  new  growths  is 
afforded  by  noticing  what  position  of  the  patient  best  re- 
lieves the  pressure-symptoms  and  modifies  the  dyspnoea. 
There  may  be  blueness  of  the  upper  part  of  the  body  and 
arms,  while  the  enlarged  thoracic  and  anastomosing  abdom- 
inal veins  stand  forth  prominent  and  distended.  According 
to  Osier,  the  distention  and  enlargement  of  the  thoracic  veins 
are  more  marked  with  lymphadenoma  than  with  cancer  or 
with  sarcoma.  The  sternum  or  the  intercostal  spaces  on 
either  side  may  be  bulged  forward  or  may  be  involved  by 
the  growth.  A  transmitted  expansion  frequently  suggests 
aneurysm,  but  it  is  not  so  marked,  there  is  no  lateral  expan- 
sion, and  there  is  no  diastolic  shock.  The  tracheal  tug  is 
seldom  if  ever  obtained,  and  over  the  tumor  no  murmur  is 
detected,  as  in  the  latter  disease.  Dulness  is  elicited  by 
percussion  over  the  growth,  either  over  the  upper  sternum 
or  between  the  spinal  column  and  the  scapula  in  case  of 
involvement  of  the  posterior  mediastinum.  The  breathing 
on  either  side  may  be  feeble  from  bronchial  compression  or 
may  assume  a  tubular  character.  The  physical  signs  are 
modified  by  the  signs  of  pleural  effusion  or  of  cancer  of  the 
lung  or  the  pericardium. 

Diagnosis. — Many  points  of  differential  diagnosis  from 
aneurysm  of  the  aorta  have  already  been  alluded  to.  In 
many  cases  a  positive  diagnosis  cannot  be  given,  although, 
should  the  patient  live  over  eighteen  months,  a  malignant 
mediastinal  growth  may  probably  be  excluded. 

The  prognosis  depends  upon  the  nature  of  the  growth. 

Treatment. — In  cases  of  lymphoma  the  administration 
of  arsenic  is  often  followed  by  a  diminution  of  the  growth. 
For  radical  cure  surgical  treatment  alone  can  avail,  but  as 
this   is   rarely  possible,  the   medicinal  treatment  is  merely 

25 


86        .V.l.VC.I/.    OF   rilE    rRACTICE    OF  MEDICIXE. 


palliatix'c.  to  quiet  the  pain  and  to  relieve  the  dj'spnoia. 
Opium  may  be  given  without  conscientious  dread  of  form- 
ing a  habit. 

ABSCESS    OF    THE    MEDIASTINUM. 

This  affection  is  usually  of  traumatic  origin  ;  it  may,  how- 
ever, be  secondar\-  to  infectious  fevers,  to  pytemia,  to  ery- 
sipelas, or  to  suppurative  disease  of  the  adjacent  viscera. 
Chronic  abscesses  are  usual!}'  of  tubercular  origin.  The 
abscess,  which  is  usually  situated  in  the  anterior  medias- 
tinum, is  more  common  in  males  than  in  females.  The  pus 
may  finally  become  inspissated  and  encapsulated,  or  it  may 
rupture  through  the  sternum,  through  an  intercostal  space, 
or  into  the  oesophagus  or  the  trachea,  or  it  may  burrow  into 
the  abdominal  cavity. 

The  symptoms  are  those  of  abscess  and  pressure.  Pain 
is  marked  from  the  start,  is  of  a  throbbing  character,  and  is 
associated  with  exquisite  tenderness.  Irregular  fever,  chills, 
and  sweating  mark  the  presence  of  pus.  Cough,  dysphagia, 
and  dyspnoea  occur  as  pressure-symptoms. 

The  prognosis  must  be  guarded,  owing  to  the  possible 
complications. 

Treatment. — In  the  earlier  stages  the  ice-bag  or  the  cold 
Leiter  coil  should  be  employed  continuously.  When  pus 
has  formed  it  may  be  evacuated  by  trephining  the  sternum. 

EMPHYSEMA    OF    THE    MEDIASTINUM. 

This  condition  is  met  with  in  trauma,  follows  the  oper- 
ation of  tracheotomy,  and  may  result  from  rupture  of  the 
peripheral  air-vesicles  of  the  lung  during  violent  cough- 
ing or  straining.  Air  may  enter  the  cellular  tissue  of  the 
mediastinum  by  perforation  of  ulcers  of  the  trachea,  the 
bronchi,  or  the  oesophagus.  The  emphysema  may  be 
limited  to  the  mediastinum,  may  rupture  into  the  pleura, 
causing  pneumothorax,  or  may  spread  to  the  neck  and  even 
to  the  entire  body.     The  treatment  is  entirely  symptomatic. 


DISEASES   OE   7V/E    I'/fYMUS   GLAND.  387 

MEDIASTINAL  HEMATOMA. 

Hemorrhage  into  the  mediastinal  tissues  occurs  in  hemor- 
rhagic conditions,  from  erosion  or  rupture  of  blood-vessels 
or  from  rupture  of  an  aneurysm. 

The  symptoms  are  those  of  hemorrhage  and  mediastinal 
pressure,  while  ecchymoses  may  appear  after  a  few  days  in 
the  lumbar  region, 

DISEASES    OF    THE    THYMUS    GLAND. 

Hypertrophy  is  occasionally  met  with  in  children ;  it 
may  cause  spasm  of  the  glottis  (thymic  asthma)  or  sudden 
death. 

Abscess  may  develop  in  syphilitic  children. 

Sarcoma  and  carcinoma  may  originate  in  the  thymus 
gland  and  may  give  the  regular  symptoms  of  tumor  in  the 
mediastinum.  The  gland  may  be  enlarged  during  the  course 
of  leukaemia  or  of  Hodgkin's  disease. 

Hemorrhages  in  the  gland-tissue  are  not  uncommon  dur- 
ing scurvy  and  purpura  haemorrhagica. 


IV.  DISEASES  OF  THE  DIGESTIVE 
SYSTEM. 


i,  DISEASES  OF  THE  OESOPHAGUS. 

ACUTE    CESOPHAGITIS. 

Etiology. — The  oesophagus  may  be  inflamed — (i)  by 
the  spread  of  inflammation  from  the  phar\-nx  or  the 
stomach  ;  (2)  by  mechanical  or  chemical  irritants  or  corro- 
sives;  (3)  by  pseudo-membranous  inflammation  secondary 
to  diphtheria  or  to  some  acute  infections ;  (4)  by  the  pus- 
tules of  variola;  (5)  in  rare  cases  oesophagitis  may  develop 
in  sucklings  without  known  cause. 

Lesions. — The  inflammation  may  be  diffuse  or  localized, 
and  either  catarrhal,  pseudo-membranous,  or  phlegmonous. 
The  pustules  of  variola  result  in  ulcerations.  There  may 
be  a  mycotic  inflammation  secondary  to  thrush  and  resem- 
bling it  in  its  pathological  features.  The  swallowing  of  cor- 
rosives is  followed  by  sloughing  and  ulceration. 

Symptoms. — Pain  on  swallowing  is  a  nearly  constant 
symptom,  and  a  continuous  substernal  ache  is  frequently 
observed.  Food  may  be  regurgitated ;  if  coated  with  blood 
or  with  pus,  ulceration  is  indicated. 

In  cases  of  caustic  poisoning  the  lips,  the  mouth,  and  the 
pharynx  exhibit  evidences  of  corrosion,  and  the  symptoms 
of  toxic  ga.stritis  are  present,  usually  with  some  associated 
shock.  Rupture  of  the  oesophagus  may  occur.  Patients 
recovering  from  the  acute  symptoms  ultimately  develop 
oesophageal  stenosis. 

Some  cases  of  acute  oesophagitis,  even  if  severe,  occa- 
sion but  a  trifling  amount  of  discomfort. 

The  treatment  of  acute  oesophagitis  consists  in  the 
administration  of  the  proper  antidote  in  case  of  corrosive 
mineral  poisons.  Demulcent  drinks  and  cracked  ice  are 
of  service    in  diminishing  the   pain   and  the  inflammation. 

388 


STENOSIS   OF   rilE    (T^SOP/MGUS.  389 

The  nourishment  should  be  bland  and  unirritating.  Fluids 
alone  should  be  given  during  the  acute  stages,  while  in 
severe  cases  rectal  alimentation  should  be  insisted  upon. 

CHRONIC    CESOPHAGITIS. 

A  chronic  catarrhal  inflammation  of  the  mucous  mem- 
brane lining  the  oesophagus  is  produced  by  improper  and 
irritating  food  and  by  the  presence  of  tumors  or  stricture 
of  the  oesophagus  itself;  or  the  chronic  form  may  result 
from  an  acute  attack. 

The  symptoms  consist  chiefly  in  the  raising  of  mucus- 
coated  regurgitated  or  vomited  food. 

The  treatment  is  that  of  the  underlying  cause. 

STENOSIS    OP    THE    CESOPHAGUS. 

Synonym. — Stricture  of  the  oesophagus. 

Stenosis  may  result — (i)  From  compression  from  without  by 
tumor  of  the  neck  or  the  mediastinum,  by  aneurysm,  by  re- 
tropharyngeal abscess,  or  by  a  large  pressure-diverticulum. 
(2)  From  obstruction  of  the  lumen  by  foreign  bodies,  and  rarely 
by  tumors  and  polypi.  (3)  From  contraction  of  the  ivall.  {a) 
There  may  be  cicatricial  contraction  following  the  healing 
of  ulcers  due  either  to  corrosive  poisons  or  to  diphtheria, 
small-pox,  or,  more  rarely,  to  syphilis  or  to  tubercular  dis- 
ease. A  rare  form  of  ulceration,  the  "  round  ulcer,"  is  seen 
at  the  lower  end  of  the  oesophagus.  This  ulcer  is  produced 
by  self-digestion  by  regurgitated  gastric  juice,  after  the  man- 
ner in  which  ulcer  of  the  stomach  is  caused,  (f)  There 
may  be  malignant  groiuth  of  the  wall,  usually  epithelioma. 
(c)  There  may  be  spasmodic  contraction  or  {d)  congenital 
narrowing  at  some  part. 

Symptoms. — In  all  cases  of  stenosis  of  the  oesophagus 
these  cardinal  symptoms  are  present — difficulty  in  swallow- 
ing, pain,  and  the  regurgitation  of  food.  The  cases  may, 
however,  conveniently  be  described  in  three  groups. 

Cicatricial  Stenosis. 
The  stricture  may  occur  at  any  part  of  the  oesophagus, 
but  it  is  most   frequent   in    the    lower  third.      The  whole 


390        M.tXr.lL    OF   THE   PKACTICE    OF  MEDICLXF. 

length  may  be  involved.  The  stenosis  may  reach  such  a 
degree  that  liquids  can  barely  trickle  through.  The 
CESophagus  above  the  stricture  is  usual!)'  much  dilated, 
and  its  walls   are  thickened. 

After  the  histor\'  of  antecedent  ulceration  the  patient 
complains  of  increasing  difficult)-  in  swallowing,  the  food 
being  cut  finer  and  finer  and  washed  down  with  water.  In 
severe  cases  liquids  alone  are  taken.  The  food  seems  to 
stick,  and  after  a  time  it  is  regurgitated.  The  lower  down 
the  stricture  is,  and  the  more  dilated  the  oesophagus  above 
it,  the  longer  the  time  after  eating  before  regurgitation 
occurs.  The  ejected  food  may  be  macerated  and  mixed 
with  mucus,  but  that  it  has  not  reached  the  stomach  is 
proved  by  the  absence  of  gastric  odor  and  by  the  alkaline 
reaction  of  the  food.  The  latter  test,  however,  is  not  infal- 
lible if  the  food  be  retained  some  hours  before  being  regur- 
gitated, because  of  the  formation  of  fatty  acids  in  it.  Pain 
is  not  a  marked  feature  except  at  the  time  of  swallowing 
the  first  bolus.  ■  • 

The  diagnosis  is  made  by  the  passage  of  the  oesophageal 
bougie.  A  conical  bougie  on  an  elastic  whalebone  stem 
should  be  employed,  but  the  soft-rubber  stomach-tube  may 
be  used.  It  is  of  the  utmost  importance,  before  passing  the 
bougie,  to  exclude  aortic  aneurysm  producing  stenosis  by 
compression,  because  of  the  danger  of  causing  rupture  of 
the  aneurysmal  sac.  The  tube  should  never  be  passed 
when  ulceration  of  the  cesophagus  from  any  cause  is  sus- 
pected. Auscultation  is  frequently  serviceable  in  cases 
where  the  bougie  cannot  be  employed.  The  auscultator, 
listening  to  the  left  of  the  dorsal  spine  while  the  patient 
swallows  a  mouthful  of  water,  hears  a  loud  splashing,  gurg- 
ling sound  at  the  site  of  the  stricture,  below  which  the 
sound  is  absent  or  only  slightly  audible  after  a  pause. 

The  prognosis  depends  upon  the  degree  of  stenosis  and 
upon  its  dilatabilit)'.  In  advanced  grades  death  may  ensue 
from  inanition  or  from  rupture  of  the  dilated  oesophagus 
above  the  stricture ;  or,  should  the  regurgitated  food  enter 
the  larynx,  suffocation  or  aspiration-pneumonia  may  result. 

Treatment. — Gradual  dilatation  by  the  persistent  use  of 


STENOSIS    OP'   THE    (ESOTI/AGUS.  39 1 

the  oesophageal  bougie  should  be  employed,  and  in  many- 
cases  the  results  are  remarkably  good.  The  diet  should 
be  compact  and  nourishing,  and  rectal  alimentation  may 
be  resorted  to.  In  advanced  cases  the  stricture  may  be 
cut,  or  an  opening  may  be  made  into  the  oesophagus 
below  the  stricture  (cesophagostomy),  or  into  the  stomach 
(gastrostomy). 

Cancerous    Stricture. 

This  form  of  oesophageal  stricture  is  usually  primary. 
Epithelioma  is  most  common;  scirrhus  and  encephaloid 
are  rare.  The  growth  usually  occurs  in  the  lower  third, 
next  in  frequency  in  the  upper  third,  of  the  oesophagus.  Be- 
ginning in  the  mucous  membrane,  it  extends  to  form  an 
annular  constriction,  usually  involving  one  or  two  inches 
of  the  tube.  Ulceration  of  the  growth  may  occur,  so  that 
the  stenosis  becomes  less  marked,  but  the  ulceration  may 
extend  and  perforate  the  lung,  the  trachea,  a  bronchus,  the 
mediastinum,  the  aorta,  or  the  pericardium.  Erosion  of 
the  vertebrae  may  occur.  Secondary  growths  in  adjacent 
lymphatic  glands  are  common.  The  oesophagus  above  the 
cancer  is  usually  dilated,  and  its  walls  are  thickened. 
♦Epithelioma  is  seen  in  patients  over  forty  years  of  age; 
it  is  more  common  in  men  than  in  women. 

The  symptoms  resemble  those  of  the  cicatricial  group  in 
their  essential  features.  Dysphagia  is  progressive,  and  it 
becomes  so  extreme  that  emaciation  and  inanition  rapidly 
result.  The  regurgitated  food  frequently  contains  blood 
and  pus  in  small  quantities,  and  it  may  contain  cancer-cells 
and  fragments.  Pain  is  a  marked  feature,  being  aggravated 
by  attempts  at  swallowing.  The  cervical  lymph-glands  are 
enlarged,  and  symptoms  of  cancerous  cachexia  are  present. 
The  oesophageal  bougie  must  be  used  with  extreme  caution 
to  avoid  penetrating  the  ulcerated  wall,  as  such  an  accident 
has  not  infrequently  occurred.  The  soft-rubber  tube  is 
generally  preferable  in  these  cases. 

The  diag-nosis  is  made  positive  by  the  finding  of  cancer- 
fragments  in  the  eye  of  the  tube.  In  cases  of  ulceration  of 
the  epithelioma  in  which  no  real  degree  of  stenosis  longer 


39-        MAXi'AL    OF   THE   PKACTJCE    OF  MFDKFXE. 

persists,  the  tube  may  pass  witliout  difficulty.  In  these 
cases,  however,  d)-sphay,"ia  and  regurgitation  of  food  may 
be  nearly  as  marked  as  if  there  were  an  actual  narrowing  of 
the  lumen ;  these  symptoms  are  to  be  explained  on  the 
theory  that  downward  peristalsis  is  checked  at  the  site  of 
the  growth,  and  that  a  reversed  peristalsis  results  in  regur- 
gitation. 

The  prognosis  is  hopeless.  Patients  usually  die,  from 
inanition,  perforation,  or  aspiration-pneumonia,  about  one 
}'ear  after  the  s}-mptoms  begin  to  be  noticed. 

The  treatment  consists  in  the  proper  feeding  of  the 
patient  b\-  nourishing  liquid  and  concentrated  food,  by  feed- 
ing through  a  stomach-tube  or  by  the  rectum.  Gastrotomy 
or  oesophagotomy  offers  but  little  chance  even  of  prolong- 
ing life. 

Spasmodic   Stenosis  (CEsophagismus). 

This  form  of  oesophageal  stenosis  occurs  chiefl)'  in  \'oung 
hysterical  women  or  in  those  with  marked  neurotic  tenden- 
cies. It  may  occur  after  an  attack  of  choking,  or  as  a 
nervous  affection  in  those  bitten  by  dogs  and  in  dread  of 
hydrophobia.  It  may  occur  from  reflex  causes,  such  as 
pregnancy,  and  it  often  complicates  organic  lesions  of  the 
oesophagus  itself 

The  lesion  consists  of  spasm  of  the  oesophageal  wall, 
usually  at  either  the  pharyngeal  or  the  cardiac  extremit)-. 
In  the  former  case  it  is  often  associated  with  spasm  of  the 
pharyngeal  muscles. 

The  symptoms  consist  of  inability  to  swallow,  regurgi- 
tation of  food,  and  a  sense  of  substernal  pain  or  constriction. 
The  dysphagia  comes  on  abruptly  and  is  not  progressive — 
two  characteristics  which  distinguish  the  spasmodic  from 
the  other  forms  of  stenosis.  There  are,  moreover,  periods 
of  marked  improvement;  or  the  dysphagia  may  be  only  for 
certain  articles  of  food,  varying  in  individual  cases.  The 
inability  to  swallow  is  never  so  extreme  as  to  endanger  the 
life  of  the  patient  by  inanition,  although  the  disease  may 
last  for  days,  weeks,  or  even  for  months.  Intermissions, 
however,   usually  mark  the   protracted   cases.     Associated 


DILATATIONS  AND   DIVEA'IICULA.  393 

hysterical  or  hypochondriacal  symptoms  are  usually  pres- 
ent, rendering  the  diagnosis  the  more  evident. 

The  prog-nosis  is  perfectly  good. 

The  treatment  consists  in  passing  the  oesophageal  bougie. 
Difficulty  may  be  encountered  by  reason  of  the  spasm,  but 
patience  and  gentleness  will  usually  succeed  in  accomplish- 
ing its  passage.  Often  a  brilliant  cure  follows  the  first  treat- 
ment, but  in  obstinate  cases  a  daily  passage  of  the  bougie 
may  be  needed,  usually  before  the  principal  meal,  to  restore 
the  confidence  of  the  patient. 

Sedatives,  such  as  valerian,  the  bromides,  and  phenacetine, 
may  be  given,  and  tonic  treatment  is  indicated  in  nearly 
every  case. 

DILATATIONS    AND    DIVERTICULA. 

Dilatation  may  be  primary  or  secondary. 

Primary  dilatation,  which  is  rare,  is  due  to  a  congenital 
defect  in  the  muscular  tissue  of  the  oesophageal  wall  or  to 
its  paralysis.  The  oesophagus  is  enormously  dilated  and  is 
usually  longer  than  normal.  The  principal  symptom  is 
dysphagia  from  lack  of  sufficient  peristalsis. 

Secondary  dilatation  occurs  with  stenosis  above  the  point 
of  constriction.  The  condition  is  to  be  suspected  if  a  patient 
with  organic  stricture  of  the  oesophagus  regurgitate  large 
quantities  of  macerated  food.  The  retention  of  such  quan- 
tities of  food  may  cause  pressure-symptoms. 

Diverticula  are  of  two  forms  : 

Pressure-divertiadinn. — This  form  is  most  common  at  the 
posterior  wall  of  the  oesophagus,  at  its  junction  with  the 
pharynx.  From  weakness  of  the  muscle  at  this  point  a 
bulging  of  the  mucous  and  submucous  coats  takes  place, 
forming  a  hernial  sac,  into  which  food  passes.  Owing  to  lack 
of  expulsive  power,  food  collects  and  becomes  macerated,  the 
sac  growing  larger  and  larger.  The  sac  may  be  emptied  from 
time  to  time  by  contraction  of  the  muscles  of  the  neck  or 
by  external  manipulation.  It  may  be  large  enough,  when 
full,  to  press  forward  and  occlude  the  oesophagus. 

The  diagnosis  is  made  by  the  presence  in  the  neck  of  a 
tumor  which  can  be  emptied  by  manipulation,  and  by  alter- 


394        M.l.yC'.lL    OF   TIIK   PRACTICE    OF  MEDICIXE. 

nately  passing;-  the  bouf^ie  dcnvn  the  tesopliai^us   and  into 
the  sac. 

Tra(tion-divcrliculuin. —  This  form  is  situated  on  the  ante- 
rior wall  of  the  cesophai;us,  opposite  the  bifurcation  of  the 
trachea.  Should  the  mediastinal  glands  normally  present 
at  this  point  become  inflamed,  they  will  enlarge  and  may 
become  adherent  to  the  wall  of  the  oesophagus  ;  b\'  the 
subsequent  contraction  of  the  glands  the  wall  is  drawn 
out  into  a  funnel  shape,  never  more  than  a  quarter  of  an 
inch  in  depth.  This  form  gives  no  symptoms,  although  in 
rare  cases  perforation  has  been  known  to  occur. 

PARALYSIS    OF    THE    CESOPHAGUS. 

This  rare  condition  develops  from  diseases  of  the  brain 
and  the  cord,  from  hysteria,  and  occasionally  as  a  post- 
diphtheritic paralysis. 

The  symptoms  consist  of  difficulty  in  swallowing.  The 
passage  of  the  bougie  reveals,  however,  no  stricture. 
Paralytic  dilatation  may  subsequently  be  developed. 

The  treatment  consists  in  nourishing  the  patient  by  the 
stomach-tube,  in  treating  the  original  cause,  and  in  faradi- 
zation of  the  oesophagus. 

RUPTURE    OP    THE    CESOPHAGUS. 

This  accident  may  occur  during  violent  and  sudden  at- 
tempts at  vomiting  in  healthy  people,  but  it  is  exceedingly 
rare,  rupture  usually  being  due  to  the  perforation  of  an 
oesophageal  ulcer  or  of  a  foreign  body. 

The  condition  is  fatal  within  a  few  days,  and  treatment  is 
merely  symptomatic. 

VARIX    OF    THE    CESOPHAGUS. 

Varicose  veins  may  develop  in  the  lower  portion  of  the 
oesophagus,  as  an  evidence  of  congestion,  of  heart  disease, 
or  of  cirrhosis  of  the  liver.  Chronic  oesophagitis  with  vomit- 
ing of  mucus  usually  results,  and  rupture  of  the  varicose 
veins  may  lead  to  fatal  hemorrhage. 


ACUTE    CATARRIlAf.    CAS7A'/'/VS.  395 

2.  DISEASES  OF  THE  STOMACH, 

ACUTE    CATARRHAL   GASTRITIS. 

Etiology  and  Synonyms. — Among  the  causes  predis- 
posing to  acute  catarrhal  gastritis  may  be  enumerated 
lesions  of  the  heart  or  of  the  liver  causing  chronic  conges- 
tion of  the  stomach,  and  any  condition  of  depreciated  health 
or  of  fever  that  renders  it  difficult  for  the  stomach  to  digest 
the  food  properly.  Gouty  individuals  are  apt  to  suffer  from 
gastritis,  and  personal  idiosyncrasy  often  plays  an  important 
role.  The  exciting  cause  is  usually  a  dietetic  error — over- 
feeding; eating  when  too  tired  to  digest  properly;  food 
unsuitable  for  digestion,  as  hot  bread,  unripe  fruit,  or  food 
improperly  cooked.  Over-indulgence  in  alcohol  is  a  frequent 
cause.  Severe  attacks  follow  the  taking  of  irritants  or  of 
tainted  meat  or  fish,  poisoned  ice-cream,  poor  milk,  or  unripe 
fruit.  Certain  articles  of  diet,  varying  with  each  individual, 
may  precipitate  an  attack.  Gastritis  is  frequently  symp- 
tomatic of  an  infectious  disease  or  fever.  Synonyms: 
Acute  gastric   catarrh ;  Acute   indigestion. 

Pathology. — The  mucous  membrane  of  the  stomach  is 
swollen,  congested,  and  covered  with  tenacious  mucus.  There 
may  be  small  submucous  hemorrhages  or  small  superficial 
erosions.  The  cells  of  the  gastric  tubules  are  swollen  and 
cloudy,  and  the  interglandular  tissue  may  be  infiltrated  with 
leucocytes.  Hydrochloric  acid  is  usually  temporarily  absent 
from  the  gastric  secretion,  being  replaced  by  lactic  acid  and 
the  fatty  acids.  The  most  frequent  seat  of  inflammation  is 
near  the  pylorus,  and  the  inflammation  may  extend  to  the 
duodenum  or,  especially  in  children,  may  involve  the  entire 
small  intestine. 

The  symptoms  are  divided  clinically  into  two  sets  of 
cases : 

I.  Simple  Gastritis  {Acute  Indigestion^. — The  appetite  is 
lost  or  is  diminished  except  for  highly-seasoned  food. 
There  are  uncomfortable  feelings  referred  to  the  stomach, 
in  some  cases  amounting  to  severe  colicky  pain.  Nausea 
is  frequently  complained  of,  and  vomiting  usually  affords 


396        M.lXrAL    OF  THE   PK.tC77CE    OF  MEDICINE. 

relief.  The  vomited  matters,  which  consist  of  undigested 
food  mixed  with  mucus  and  bile,  are  of  an  acid  reaction 
from  the  presence  of  lactic  and  fatty  acids.  The  patient 
complains  of  headache,  depression,  and  prostration.  The 
tongue  is  coated  and  the  breath  is  offensive.  The  bowels 
are  usually  constipated,  although  diarrluLa  ma\-  follow  the 
attack.  Fever  usually  is  slight,  although  in  some  cases 
the  temperature  may  reach  102°  or  104°  F.  The  abdomen 
is  usually  somewhat  distended  and  tender  in  the  epigastric 
region.  Herpes,  urticaria,  or  erythema  may  appear,  espe- 
ciall}'  in  cases  caused  by  eating  shell-fish. 

In  young  infants  vomiting,  fever,  and  prostration  are  the 
principal  symptoms.  In  the  symptomatic  gastritis  of  infec- 
tious disease,  vomiting  and  increased  prostration  are  the 
prominent  symptoms.  The  vomiting  may  be  so  excessive 
as  to  interfere  with  the  nourishment  of  the  patient. 

2.  Gastritis  from  Ptovidiiic-poisoni)ig. — This  form  of  gas- 
tritis follows  the  eating  of  tainted  meat  or  fish  or  of  ice- 
cream containing  the  alkaloidal  poison  tyrotoxicon.  Cases 
frequently  occur  in  small  epidemics  among  those  who  have 
eaten  of  some  particular  article  of  food.  The  symptoms  are 
those  of  a  severe  gastritis,  with  marked  prostration  and  in- 
cessant vomiting.  In  severe  cases  constitutional  symptoms 
of  an  alarming  nature  appear;  the  pulse  becomes  rapid,  the 
heart's  action  feeble,  the  skin  becomes  cold  and  clammy, 
and  the  patient  is  apt  to  die. 

Treatment  of  Gastritis. — The  first  indication  is  to  rid  the 
stomach  of  whatever  is  irritating  it.  Nature  often  does  this 
by  the  vomiting,  otherwise  a  simple  emetic  is  usually  indi- 
cated. The  bowels  should  be  opened,  castor  oil  or  saline 
laxatives  usually  being  employed  for  this  purpose,  although 
blue  mass  or  calomel  is  often  beneficial.  A  natural  diarrhoea 
should  not  be  checked.  Should  it  be  excessive  and  exhaust- 
ing, a  dose  of  castor  oil  (.5ss)  and  tincture  of  opium  (TTL  xv) 
in  combination  should  be  given.  Tlie  diet  should  be  light 
and  easily  digestible.  These  rules  suffice  for  the  majority 
of  mild  cases.  In  more  severe  cases  the  stomach  should 
have  a  rest  and  food  should  be  interdicted  for  a  day, 
although  cracked  ice  and  carbonated  waters  may  be  given 


TOXIC  GAS'J-h'/'JfS.  397 

freely.  When  the  vomiting  is  constant,  rectal  alimentation 
may  be  resorted  to.  Distressing  symptoms  should  be  con- 
trolled by  appropriate  medication.  The  vomiting  should 
not  be  checked  until  the  stomach  is  empty ;  after  that 
bismuth  in  full  doses,  bicarbonate  of  soda,  oxalate  of  cerium, 
or  even  small  doses  of  codeia  or  of  morphine,  may  be  given. 
Pain  is  best  relieved  by  emesis,  by  counter-irritation  over 
the  stomach,  by  poultices  or  mustard  pastes,  and  by  the  ad- 
ministration of  large  doses  of  bismuth.  Codeia  or  hypo- 
dermic injections  of  morphine  are  to  be  given  only  in  severe 
cases.  Stimulants  may  be  indicated  in  the  gastritis  of 
ptomaine-poisoning. 

TOXIC    GASTRITIS. 

This  form  of  gastritis  follows  the  swallowing  of  concen- 
trated acids,  alkalies,  or  irritants,  frequently  taken  with 
suicidal  intent,  or  of  certain  non-corrosive  poisons  like  phos- 
phorus, arsenic,  and  antimony.  In  the  former  case  the 
mucous  membrane  of  the  mouth,  the  oesophagus,  and  the 
stomach  is  marked  with  areas  of  necrosis  surrounded  by 
zones  of  intense  inflammation,  while  the  submucosa  is 
hemorrhagic  and  infiltrated  with  serum.  In  severe  cases 
perforation  of  the  stomach  may  occur.  In  the  non-corrosive 
poisons  the  process  consists  in  fatty  degeneration  of  the 
glandular  elements,  small-celled  infiltration  of  the  entire 
glandular  connective  tissue,  and  hemorrhage. 

The  symptoms  are  intense  burning  pain  in  the  mouth, 
throat,  and  stomach,  difficulty  in  swallowing,  and  constant 
vomiting,  the  vomited  matters  usually  containing  blood,  and 
frequently  containing  portions  of  necrosed  mucous  mem- 
brane. The  abdomen  is  distended  and  exquisitely  tender. 
In  very  severe  cases  symptoms  of  collapse  appear ;  the  pulse 
is  rapid  and  feeble,  the  skin  is  cold  and  clammy,  and  there 
is  great  prostration,  frequently  interrupted  by  restlessness 
or  by  convulsive  movements.  Albumin  is  usually  present 
in  the  urine,  and  there  may  be  hematuria.  Perforation  of 
the  stomach  is  followed  by  death  in  collapse  within  a  few 
hours.     If  the  patient  recovers  there  may  result  stricture 


398      m,l\l:il  of  the  rRAcrict  of  mfdicixe. 

of  the  CEsophagus  or  extensive  cicatrices  in  the  stomach,  lead- 
ing to  chronic  atroph)'  and  inanition. 

The.  treatment  is  that  of  severe  gastritis.  Emetics  should, 
however,  not  be  given,  on  account  of  the  danger  of  causing 
perforation.  Siphonage  of  the  stomach  is  preferable,  a  soft- 
rubber  stomach-tube  being  passed  with  caution,  and  the 
stomach  being  washed  with  solutions  of  the  appropriate 
chemical  antidote.  Hypodermic  injections  of  morphine 
are  needed  to  allay  the  pain  and  distress.  Rectal  alimen- 
tation is  usually  necessary;  it  should  be  resorted  to  in  the 
severer  cases. 

ACUTE    CROUPOUS    GASTRITIS. 

Synonyms. — Diphtheritic  gastritis ;  Membranous  gastritis. 

Croupous  gastritis  may  occur  as  a  secondary  infection 
with  diphtheria,  but  is  more  common  as  a  secondar}-  pro- 
cess in  pneumonia,  t}'phus  and  t\-phoid  fever,  pyaemia,  puer- 
peral fever,  and  Asiatic  cholera. 

The  symptoms  are  those  of  an  intense  gastritis  together 
with  those  of  the  primary  disease. 

The  diagnosis  cannot  be  made  during  life. 

The  treatment  is  that  of  the  severer  forms  of  gastritis. 

ACUTE    SUPPURATIVE    GASTRITIS. 

Etiolog-y  and  Synonyms. — This  uncommon  disease  oc- 
curs more  often  in  men  than  in  women.  It  is  rare  as  a  primary 
disease,  usually  occurring  after  pyaemia,  puerperal  fever,  or 
other  septic  diseases.  It  may  also  complicate  the  course  of 
carcinoma  of  the  stomach.  Syno)iy»is  :  Phlegmonous  gas- 
tritis ;   Purulent  gastritis. 

Pathology. — The  lesion,  which  consists  in  a  suppurative 
process  in  the  submucosa,  presents  itself  in  two  forms — a 
diffused  purulent  infiltration,  and  a  localized  abscess  ;  in  the 
latter  case  rupture  may  occur  into  the  stomach  or  into  the 
peritoneal  cavity. 

The  symptoms  are  those  of  gastritis  and  of  a  severe  in- 
fection. There  is  severe  pain  in  the  stomach,  usually  with 
exquisite  tenderness  in  the  epigastrium.  If  the  abscess  be 
large,  it  may  be  felt  externally.     Vomiting  is  persistent  and 


CHRONIC  CATARRHAL    GASTRITIS.  399 

agonizing,  and  the  vomited  matters  may,  in  rare  instances, 
contain  pus.  Jaundice  has  occurred  in  a  few  instances. 
Peritonitis  may  occur  as  a  terminal  event. 

The  symptoms  of  general  infection  are  an  irregular  fever 
ranging  between  102°  and  105°  F.,  rapid  and  feeble  pulse, 
prostration,  delirium,  and  finally  coma.  The  disease  may 
in  rare  instances  run  a  subacute  course,  with  pain,  vomiting, 
irregular  fever,  and  erratic  chills. 

The  diagnosis  is  made  with  the  utmost  difficulty,  espe- 
cially in  primary  cases.  Aid  may  be  afforded  if  the  abscess 
be  large  enough  to  be  appreciated  by  the  touch  and  if  vom- 
iting of  a  large  amount  of  pus  occur. 

Prognosis  is  fatal,  except  in  rare  cases  in  which  a  localized 
abscess  ruptures  into  the  cavity  of  the  stomach  or  into  the 
colon. 

The  treatment  is  simply  palliative. 

MYCOTIC    AND    PARASITIC    GASTRITIS. 

The  invasion  of  the  stomach  by  the  bacillus  of  diphtheria 
and  the  pus  organisms  of  phlegmonous  gastritis  has  already 
been  described.  A  fatal  case  of  the  growth  of  favus  has 
been  reported.  The  tubercle  bacillus  may  involve  the  gas- 
tric mucous  membrane,  while  sarcinae  and  the  yeast  fungus 
are  frequently  found  in  cases  of  fermentation  and  in  dilated 
stomachs,  and  serve  to  increase  the  inflammation. 

Ascarides,  taeniae,  earth-worms,  maggots,  and  the  larvae 
of  certain  dipterae  have  been  found  to  be  the  cause  of  acute 
gastritis. 

CHRONIC    CATARRHAL    GASTRITIS. 

Synonyms. — Chronic  dyspepsia;  Chronic  gastric  catarrh  ; 
Atrophy  of  the  stomach. 

Etiology. — The  causes  of  chronic  gastritis  are  various 
and  may  be  classified  as  follows  : 

Dietetic  Causes. — Among  these  may  be  enumerated  over- 
eating, over-indulgence  in  ice-water  during  meals,  rapid 
eating,  irregular  meals,  improperly  cooked  and  unsuitable 
food,  such  as  rich  fried  food,  pastries,  or  hot  bread,  and  the 
abuse  of  alcohol,  tea,  or  tobacco. 


400       MAXi'AL    OF   THE   PRACTICE    OF  MEDICINE. 

Constitittioiiol  Oriiscs. — Chronic  gastritis  may  be  produced 
by  any  debilitating  disease  which  reduces  nervous  force  or 
deteriorates  the  blood.  The  food,  not  being  digested  prop- 
erly, is  retained  in  the  stomach,  ferments,  and  sets  up  a 
chronic  inflammation.  In  this  way  the  gastritis  is  often 
associated  with  auitmia,  chlorosis,  tuberculosis,  Bright's 
disease,  diabetes,   gout,  and   uterine  disease. 

Local  Causes. — The  disease  may  be  secondary  to  lesions 
of  the  stomach,  such  as  cancer,  ulcer,  or  dilatation,  or  it 
may  follow  passive  congestion  of  the  mucous  membrane  as 
in  cirrhosis,  or  in  any  obstruction  to  the  portal  circulation, 
chronic  heart  disease,  and  certain  diseases  of  the  lung  pro- 
ducing general  venous  congestions. 

Pathology. — Three  forms  of  chronic  gastritis  are  de- 
scribed— a  simple,  a  sclerosing,  and  an  atrophic. 

1.  Si  III  pi i  Chronic  Gastritis. — The  mucous  membrane  is 
thickened,  grayish,  or  congested  in  appearance,  and  is 
covered  with  thick  tenacious  mucus.  The  veins  are  usually 
congested,  and  patches  of  pigmentation  from  small  sub- 
mucous hemorrhages  are  common,  especially  near  the 
pylorus.  The  membrane  frequently  has  a  granular  or 
reticular  appearance  from  irregular  growth  of  connective 
tissue.  The  connectix'e  tissue  and  the  muscular  coats  are 
usually  also  thickened,  especially  around  the  pylorus.  The 
gastric  tubules  are  atrophied,  cystic,  or  deformed,  the  cells 
are  the  seat  of  a  mucoid  degeneration,  and  between  the 
tubules  there  is  an  abundant  small  celled  infiltration.  In 
very  mild  cases  the  mucous  degeneration  of  the  cells  of  the 
tubules  may  constitute  the  only  lesion.  In  uncomplicated 
cases  there  is  no  increase  in  the  actual  size  of  the  stomach. 

2.  Sclerosing  Gastritis  (or  Sclerotic  Gastritis). — In  this 
form  the  hypertrophic  changes  of  the  connective  tissue  and 
muscular  coats  are  exceedingly  marked,  and  especially  about 
the  pylorus.  There  maybe  a  resulting  pyloric  stenosis  with 
a  secondary  dilatation  of  the  stomach.  There  is  a  rare  form 
in  which  the  walls  of  the  stomach  become  converted  to 
cirrhotic  connective  tissue,  and  is  attended  by  a  diminution 
in  the  size  of  the  stomach.  To  this  form  the  term  "  cirrho- 
sis ventriculi  "  or  cirrhotic  atrophy  has  been  applied. 


CHRONIC   CATARRJIAI.    GAS7'A'/77S.  4OI 

3.  Atrophic  Gastritis. — This  form  may  occur  as  a  terminal 
process  of  the  first  variety  or  may  be  atrophic  from  the 
start.  The  wall  of  the  stomach  is  thinned,  the  mucous 
membrane  is  thin,  smooth,  and  hght  grayish  in  color ;  its 
glandular  elements  undergo  fatty  degeneration  and  atrophy. 
In  advanced  cases  nothing  remains  of  the  mucous  membrane 
but  a  layer  of  round  cells,  a  few  cysts,  and  fibrous  tissue. 
To  this  condition  the  term  "  achylia  gastrica "  has  been 
given. 

Symptoms. — Three  clinical  forms  may  be  recognized  : 
I.  Simple  gastritis.  2.  Sclerosing  gastritis.  3.  Atrophic 
gastritis. 

I.  Simple  Gastritis. — Distress  or  oppression  in  the  stom- 
ach is  a  fairly  constant  symptom.  It  usually  is  slight,  but 
in  rare  cases  it  amounts  to  actual  pain,  never  severe  enough, 
however,  to  cause  the  patient  to  vomit,  as  in  gastric  ulcer. 
It  usually  occurs  after  eating,  but  it  may  be  more  or  less 
constant,  and  in  some  cases  is  aggravated  when  the  stomach 
is  empty.  In  other  cases  the  pain  consists  of  a  burning 
feeling  under  the  sternum  due  to  hyperacidity,  and  may  be 
associated  with  eructations  of  a  sour  acid  fluid.  There  may 
be  tenderness  over  the  stomach,  more  commonly  diffused 
and  rarely  severe.  The  appetite  is  usually  impaired,  although 
some  patients  complain  of  unnatural  hunger.  There  maybe 
appetite  only  for  highly  seasoned  or  peculiar  articles  of  food. 
Flatulence  is  not  a  marked  symptom  unless  gastric  atony  is 
present  as  a  complication.  Nausea  and  vomiting  are  com- 
monly observed,  and  are,  in  large  measure,  dependent  upon 
the  quality  and  quantity  of  food.  The  vomited  matters  are 
not  abundant,  and  consist  of  food  in  various  stages  of  di- 
gestion mixed  with  mucus.  Small  quantities  of  blood, 
either  bright  red,  or  darker,  from  alteration  of  the  blood- 
pigment,  may  be  vomited  from  time  to  time.  A  special 
form  of  vomiting  is  commonly  seen  in  alcoholic  cases,  occur- 
ring in  the  morning,  and  consisting  of  mucus,  bile,  and  saliva 
that  has  been  swallowed  during  the  night.  "  Dry  retching" 
in  the  morning  is  also  common  in  the  alcoholic  cases. 

The  tongue  is  usually  heavily  coated,  and  is  indented  by 
the    teeth.     The  edges  and   tip  may  be  red,  and  in  some 


402        MAXr.lL    OF  THE   PRACTICE    OF  MEDICIXE. 

cases  the  whole  tongue  has  a  "  red-beef"  appearance.  The 
breath  is  usuall}-  offensive,  and  a  bad  taste  in  the  mouth  is 
complained  of,  especiall)'  in  the  morning.  Saliva  and 
the  phar\-ngeal  secretions  are  usualh'  increased,  and  the 
patient  may  comj^lain  of  a  cough,  the  "  stomach-cough," 
usual!}'  of  pharyngeal  irritation.  Tiic  urine  may  be  dimin- 
ished in  quantity,  of  high  specific  gravit)',  and  may  deposit 
uric  acid,  urates,  phosphates,  or  calcium  oxalate.  The 
patient  loses  flesh  and  strength  in  accordance  with  the 
gravity  of  the  case ;  this  symptom  is  the  most  reliable 
means  of  estimating  the  true  extent  of  the  inflammation. 

From  the  passage  of  undigested  food  into  the  intestine  an 
enteritis  may  result,  or  a  functional  disturbance  of  the  liver 
may  be  induced,  adding  its  symptoms.  Among  these 
symptoms  may  be  cited  hot  and  cold  flashes,  marked 
enough  to  suggest  malaria  to  the  patient,  headache,  dizzi- 
ness, and  an  inaptitude  for  mental  and  physical  work. 
Marked  dizziness,  however,  does  not  occur  unless  there  is 
a  complicating  atony.  The  motor  power  of  the  stomach  is 
good,  fermentation  does  not  ordinarily  occur,  and  vomiting 
of  food  eaten  some  time  previously  is  not  a  symptom. 

In  many  cases  classical  symptoms  are  entirely  wanting, 
and  the  occurrence  of  a  gastric  disorder  may  be  known 
only  by  gastric  analysis.  In  other  cases  the  symptoms  are 
those  of  a  nervous  indigestion.  In  some  cases  anaemia  and 
constipation  are  the  only  symptoms  noted.  In  other  cases 
the  patients  complain  of  intestinal  flatulence,  constipation,  or 
a  tendency  to  diarrhoea,  pressure  and  pain  in  the  abdomen, 
and  by  the  test-breakfast  a  gastritis  is  found,  giving  rise  to 
the  enteritis  from  which  the  symptoms  arise. 

2.  Sclerosing  Gastritis. — In  this  form  the  symptoms  of 
gastritis  are  obscured  by  those  of  gastric  dilatation.  The 
clinical  picture  is  one  of  pyloric  stenosis,  and  a  diag- 
nosis from  carcinoma  may  be  made  with  difficulty,  espe- 
cially when  the  thickening  about  the  pylorus  is  felt  as  a 
tumor  through  the  abdominal  wall.  If  lactic  acid  is  present 
with  absence  of  HCl,  a  differential  diagnosis  may  be  im- 
possible.    Hemorrhage  does  not,  however,  occur. 

In  cases  of  "  cirrhotic  atrophy  "  there  may  be  inability  of 


CHRONIC  CATARRHAL    GASTRIRIS.  4O3 

the  stomach  to  hold  more  than  a  small  amount  of  nourish- 
ment at  any  one  time. 

3.  Atropine  Gastritis. — There  is  entire  absence  of  any 
digestive  power  whatever  in  the  stomach.  The  symptoms 
are  those  of  severe  dyspepsia  with  failing  nutrition.  Vomit- 
ing is  a  prominent  feature,  and  there  may  be  lancinating 
pains,  not  always  dependent  on  food,  the  clinical  picture 
resembling  that  of  cancer.  In  other  cases  a  progressive 
anaemia  is  developed,  resembling  pernicious  anaemia,  and 
occurs  whenever  the  intestinal  mucous  membrane  becomes 
atrophied  in  like  manner  to  that  of  the  stomach. 

Gastric  Analysis. — Although  the  diagnosis  may  be  sus- 
pected by  the  clinical  symptoms,  a  gastric  analysis  should 
in  every  case  be  made,  not  only  to  establish  the  diagnosis, 
but  to  afford  the  only  positive  indications  for  treatment. 
The  results  of  gastric,  analysis  are  very  different  in  the 
three  clinical  types. 

Simple  Gastritis. — In  the  fasting  condition  mucus  is  found, 
usually  bile-stained  and  alkaline,  although  in  some  cases 
there  may  be  reactions  for  free  HCl.  There  are  no  food- 
remains,  showing  that  the  motor  power  of  the  stomach  is 
good.  The  gastric  contents  one  hour  after  the  Boas  test- 
breakfast  show  presence  of  mucus,  and  the  food  more  or 
less  imperfectly  digested.  In  the  majority  of  cases  the 
total  acidity  is  low ;  free  HCl  is  scanty  or  absent,  the 
greater  part  of  the  total  acidity  being  furnished  by  the 
combined  acid. 

In  moderate  cases  the  total  acidity  falls  to  20  or  30,  in 
more  marked  cases,  to  10  or  12.  In  these  cases  of  low 
acidity  the  ferments  are  reduced  or  absent.  The  zymo- 
gens, however,  are  more  constantly  present,  and  in  simple 
cases  should  be  present  in  dilutions  of  yb-q.  If  rennet  zymo- 
gen be  active  in  j^  dilution,  the  prognosis  is  good ;  when 
inactive  in  dilutions  under  -gY,  the  prognosis  is  uncertain  ; 
when  inactive  in  dilutions  under  -^,  the  prospect  of  recover}^ 
is  slight.  In  other  cases  there  is  hyperacidit}-,  the  gastric 
inflammation  acting  as  an  irritative  lesion  upon  the  glandular 
cells.  This  form  of  hyperacid  gastritis  is  especially  seen 
when  there  is  a  complicating  gastric  atony,  and  is  not  at  all 


404        J/.I.VC.IL    OF   THE   PKACriCl:    OF  MKD1CL\'E. 

uncommon.  Starch  digestion  is  good  with  subacidity,  poor 
with  high  acidity.  Lactic  acid  and  fatty  acids  do  not  appear. 
Microscopically  there  are  no  striking  abnormalities. 

Sclerosing  Gastritis. — Tiie  fasting  stomach  shows  the 
presence  of  food-remains  in  various  stages  of  digestion  and 
fermentation.  The  test-breakfast  usually  shows  marked 
reduction  in  free  and  combined  HCl.  Lactic  acid  may  be 
present.  Li  rarer  cases  the  gastric  analysis  resembles  that 
of  benign  pyloric  stenosis  of  cicatricial  origin. 

Atropine  Gastritis. — The  fasting  stomach  is  empty,  both 
of  food-remains  and  of  mucus.  The  test-breakfast  shows 
entire  absence  of  digestion.  Il^-drochloric  acid,  both  free 
and  combined,  the  ferments,  organic  acids,  and  mucus  are 
ail  absent ;  the  zymogens  are  absent  or  greatly  reduced. 

Prognosis. — The  course  is  essentially  chronic,  with 
periods  of  improvement  from  time  to  time.  The  symptoms 
often  come  and  go,  depending  on  the  general  health  and 
upon  the  thoroughness  and  efficacy  of  the  treatment. 
Although  mild  cases  are  recovered  from,  a  guarded  prog- 
nosis should  be  gi\-cn  if  tlie  disease  has  lasted  any  length 
of  time.  Relapses  ma}^  be  induced  by  trifling  indiscretions. 
A  better  prognosis  can  be  gi\'en  if  no  intestinal  catarrh 
exists.  The  danger  of  atrophy  must  be  considered  in  severe 
and  long-continued  cases,  for  this  condition  tends  to  shorten 
life  by  inanition  and  anaemia. 

Treatment. — Dietetic  and  Hygioiic. — Detailed  attentior. 
should  be  paid  to  the  correction  of  all  dietetic  errors  that 
may  seem  causative  of  the  disorder.  The  patient  should 
not  eat  hurriedly,  nor  should  he  eat  heartily  when  too  tired 
to  digest  properly,  nor  indulge  in  severe  exercise  after  a 
hearty  meal.  Due  attention  should  be  paid  to  the  condi- 
tion of  the  mouth  and  teeth.  Careful  supervision  should 
be  made  as  to  the  maintenance  of  general  health.  The 
patient  should  have  sufficient  sleep,  exercise,  and  fresh  air. 
Ansemic  and  weakly  conditions  should  be  combated  by 
appropriate  medication.  Change  of  air  and  travel  will 
frequently  do  more  than  all  other  means  combined. 

The  surest  indications  for  diet  are  found  by  gastric  anal- 
ysis.    In  cases   of  normal  or  increased  acidity,  meats  are 


CHRONIC  CATARRHAL    GASIRITIS.  405 

allowed,  while  if  the  acidity  be  low,  meats  are  to  be  given 
sparingly  or  replaced  by  fish  or  one  of  the  concentrated 
nitrogenous  foods,  such  as  somatose,  nutrose,  or  plasnion. 
In  severe  cases  the  food  should  be  finely  prepared,  the 
meats  scraped  or  hashed,  the  vegetables  in  the  form  of 
puree  or  thickly  creamed.  Cereals,  as  a  rule,  are  well 
digested,  especially  in  cases  with  subacidity. 

Milk  is  usually  well  borne,  except  in  cases  of  high  acidity. 
Stimulants,  spices,  highly  seasoned  food,  and  food  well 
known  to  be  difficult  of  digestion,  such  as  pork,  cabbage, 
and  new  veal,  should  be  excluded,  and,  as  a  rule,  tea  or 
cocoa  should  be  used  instead  of  coffee.  Too  much  iced 
water  should  not  be  taken  during  the  meals.  When  con- 
stipation exists,  honey,  fruit  compotes,  and  buttermilk  should 
be  added,  with  or  without  the  help  of  enemata,  so  that 
cathartics  by  the  mouth  can  be  positively  discontinued. 

The  number  of  the  meals  depends  upon  the  motor  con- 
dition of  the  stomach-wall  and  upon  the  acidity.  High 
acidity  and  atony  if  present  are  to  be  treated  by  frequent 
feedings ;  otherwise,  three  meals  a  day  are  sufficient. 

Mechanical. — When  mucus  is  present  in  the  stomach, 
lavage  is  an  almost  indispensable  mode  of  treatment;  not 
only  does  it  free  the  stomach  from  its  mucus,  but  seems  to 
exert  a  stimulating  effect  upon  glandular  activity.  The 
stomach  should,  by  preference,  be  washed  in  the  morning 
before  breakfast  and  the  process  continued  until  the  wash 
water  is  entirely  clear.  If  the  mucus  is  tenacious,  the  addi- 
tion of  lime-water  to  the  water  (sj-Oj)  is  to  be  advised. 
The  addition  of  antiseptics  is  not  necessary. 

The  results  of  lavage  are  extremely  good,  and  in  the 
majority  of  cases,  when  combined  wdth  dietetic  rules,  con- 
stitute a  sufficient  treatment.  If  gastric  atony  coexists,  so 
that  it  is  impossible  to  get  the  lavage-water  out  of  the 
stomach,  the  advisability  of  washing  the  stomach  is  ques- 
tionable. When  over  a  pint  of  residual  lavage-water 
remains,  it  is  contraindicated.  In  these  cases  an  intro- 
ductory treatment  by  intragastric  faradism  will  strengthen 
the  stomach  to  such  a  degree  that  lavage  becomes  possible 
without  leavincr  an  excess  of  residual  water. 


406        MAXL'AL    OF  THE   PRACTICE    OF  MEDICIXE. 

The  use  of  mineral  waters  is  of  the  greatest  service,  for 
by  their  administration  glandular  activity  may  be  stimulated, 
and  hydrochloric  acidity  be  brought  toward  the  normal. 
In  catarrhal  gastritis,  when  the  hydrochloric  acid  is  greatly 
reduced,  Kissingen  water  (Racoczy)  is  to  be  used,  but  it  is 
of  no  benefit  if  acidity  be  entirely  absent.  With  moderately 
reduced  acidity,  Wiesbaden  (Kochbrunncn) ;  with  normal 
or  increased  acidity  and  over-production  of  mucus,  Carlsbad 
is  to  be  employed.  Small  doses  onl)-  should  be  given  (one- 
half  glass  of  the  natural  water,  or  a  similar  quantity  of  the 
artificial,  made  by  adding  the  artificial  powder  to  water),  and 
should  be  taken  in  the  fasting  condition. 

Medicinal. — With  proper  dietetic  and  mechanical  treat- 
ment, there  need  be  but  little  resort  to  drugs.  Certain 
symptoms,  howe\-er,  may  require  special  treatment. 

Loss  ©f  appetite  is  best  combated  by  lavage  and  the  ap- 
propriate mineral  water.  Among  the  best  of  the  stomachic 
tonics  are  condurango,  nux  vomica,  and  small  doses  of 
creasote. 

Nausea  and  vomiting,  if  uncontrolled  by  diet  and 
lavage,  may  be  treated  by  rest,  hot  applications  to  the 
abdomen,  and  small  doses  of  chloral  (gr.  ij)  and  chloro- 
form-water (.^j). 

The  use  of  hydrochloric  acid  and  pepsin  is  largely  in 
vogue,  but  not  much  is  to  be  expected  from  their  employ- 
ment. The  largest  dose  of  hydrochloric  acid  that  could  be 
given  by  the  mouth  has  very  little  effect  in  raising  the  acidity 
of  an  ordinarily  small  meal,  certainly  the  ordinary  doses 
of  lo  to  20  minims  of  the  dilute  acid  arc  without  appreciable 
result.  As  the  motor  power  of  the  stomach  is  good  and  as 
stagnation  of  food  does  not  occur,  there  is  no  indication 
for  the  acid  to  be  given  in  the  fasting  condition  for  its  dis- 
infecting effect.  Empirically,  however,  20  to  30  minims  of 
the  dilute  acid  may  be  given  after  or  during  meals,  and 
seems,  in  certain  cases,  to  increase  the  appetite,  acting  as  a 
stomachic  tonic. 

Pepsin  is  entirely  useless.  If  HCI  is  present  in  the 
stomach,  an  abundant  supply  of  pepsin  is  also  present, 
and  in  the  absence  of  HCI,  pepsin  is  inert. 


ATONY.  407 

The  treatment  of  sclerosing  gastritis  is  that  of  benign 
pyloric  stenosis,  by  lavage  and  by  surgical  operation. 

In  atrophic  gastritis,  food  suitable  for  intestinal  digestion 
should  be  given.  Frequent  meals  are  to  be  given,  and  the 
food  should  be  finely  divided.  In  these  cases  pancreatin 
with  sodium  bicarbonate  is  of  service. 

ATONY. 

Synonyms. — Muscular  insufficiency ;  Myasthenia  gas- 
trica.  A  condition  with  dyspeptic  symptoms,  characterized 
by  the  complete  but  delayed  passage  of  food  from  the 
stomach  into  the  intestine. 

Etiology. — Primary  cases  follow  irregular  modes  of  life, 
and  persistent  overloading  of  the  stomach  with  solids  or 
liquids.  It  may  be  induced  by  any  depreciation  of  physical 
or  mental  tone,  and  accompanies  conditions  of  malnutrition. 
It  is  one  of  the  local  manifestations  of  a  general  neuras- 
thenia, and  often  occurs  in  a  number  of  members  of  a  family. 
It  is  frequently  seen  after  diphtheria,  typhoid  fever,  or  in- 
fluenza, less  frequently  after  other  exhausting  diseases.  It 
occurs  as  a  complication  of  a  variety  of  gastric  disorders. 
Atony  especially  complicates  gastroptosis,  and  is  one  of  the 
chief  factors  in  inducing  the  symptoms  of  this  condition. 
With  nervous  indigestion,  carcinoma,  and  perigastric  adhe- 
sions it  occurs  very  commonly.  To  a  less  extent  does  it 
occur  with  ulcer  and  chronic  gastritis. 

Pathology. — There  is  a  simple  muscle  weakness  of  the 
gastric  wall  without  any  essential  lesion. 

Symptoms. — There  is  distress  after  eating,  described 
usually  as  a  "  load  "  or  "  weight."  The  distress  is  propor- 
tionate to  the  quantity,  but  not  to  the  quality  of  food, 
liquids  furnishing  the  same  amount  of  discomfort  as  solids. 
The  oppression  appears  usually  one-quarter  to  one-half 
hour  after  meals,  and  gradually  disappears,  so  that  the 
patient  is  relieved  when  the  stomach  is  empty.  In  severe 
cases  the  distress  is  more  continuous. 

Sensations  of  hunger  may  be  appreciated,  but  the  appe- 
titite  is  too  quickly  appeased  by  a  few  mouthfuls  of  food. 
In  other  cases  the  appetite  is  totally  lost. 


40S        J/.l.Vr.lL    OF  THE    PKACriCE    OF  iVEDICIXE. 

Gas  in  the  stomach  is  a  prominent  symptom,  and  occurs 
both  after  meals  and  in  the  fasting  condition,  so  that  it  is 
ver)'  co,mmon  for  the  patient  to  awake  early  in  the  morning 
with  flatulence.  The  gas  is  not  easil)-  raised,  owing  to  the 
poor  expulsive  power  of  the  stomach.  There  may  be  an  odor 
to  the  eructated  gas  of  food  eaten  some  time  previous  ;  this 
symptom  is  not  only  very  suggestive  of  atony,  but  gives  in 
addition  a  very  good  means  of  estimating  its  severity — the 
longer  after  eating  the  eructated  gas  retains  the  odor  of 
ingested  food,  the  longer  the  retention  of  food  within  the 
stomach.  The  eructated  gas,  however,  is  not  offensive,  as 
in  dilatation. 

There  is  usually  hyperacidity  with  any  or  all  of  its  symp- 
toms, heart-burn  at  height  of  gastric  digestion,  and  eructa- 
tions of  sour  fluid  relieved  by  alkalies.  The  bowels  are 
usually  constipated.  Gastric  vertigo  is  more  common  with 
atony  than  with  all  the  other  gastric  disorders  combined. 

Physical  Examination. — It  is  important  to  determine 
the  size  and  position  of  the  stomach,  as  an  underlying 
gastroptosis  predisposes  regularly  to  atony,  and  its  detec- 
tion affords  strong  presumptive  evidence  of  an  existing 
aton\-. 

If  six  ounces  of  water  are  given  in  the  fasting  condition, 
there  should,  normally,  be  no  succussion  sounds  over  the 
stomach  by  quick  vertical  tapotement.  If,  however,  suc- 
cussion sounds  are  present,  atony  exists,  and  the  lower 
limit  of  these  sounds  gives  a  fairly  definite  idea  of  the  lower 
border  of  the  stomach.  Succussion  sounds  may  also  be 
elicited  when  fluid  contents  are  present  in  the  transverse 
colon,  but  as  the  bowels  are  almost  regularly  constipated 
in  these  cases,  a  mistake  should  hardly  ever  be  made. 

Lavage  in  these  cases  usually  results  in  a  large  quantity 
of  residual  water  that  cannot  be  syphoned  or  expressed,  in 
most  cases  varying  between  15  and  25  ounces. 

Gastric  Analysis. — If  the  patient  is  given  the  Boas 
dinner  of  two  meat  sandwiches  and  ten  ounces  of  water 
at  nine  o'clock  at  night,  the  stomach  should  be  empty  the 
following  morning,  showing  the  ability  of  the  .stomach  to 
empty  itself  if  given    sufficient  time.     In    some  cases  the 


ATONY.  409 

stomach  may  contain  a  liquid  consistinc,^  of  mucus,  bile, 
and  hydrochloric  acid,  but  microscopically  there  are  no 
food-remains. 

The  test-breakfast  shows  usually  a  high  degree  of  acidity, 
the  prolonged  stay  of  food  within  the  stomach  acting  as  an 
irritative  lesion.  In  long-standing  cases  the  secretory 
power  of  the  stomach  may  be  exhausted  and  subacidity 
may  result.  The  gastric  contents  contain  no  previous  food- 
remains  as  in  dilatation,  and  offensive  fermentation  does  not 
occur.  Lactic  acid  is  not  present.  The  quantity  of  test- 
breakfast  expressed  is  usually  greater  than  normal.  In 
many  cases  the  test-breakfast  is  obtained  by  aspiration  of 
gastric  contents  only. 

Prog-nosis.— The  course  of  atony  is  slow,  although  sub- 
ject to  great  variations  in  the  severity  of  symptoms.  The 
prognosis  largely  depends  upon  the  ability  of  the  patient 
to  carry  out  a  sustained  course  of  treatment,  and  upon 
the  recuperative  power  of  each  individual  patient.  The 
prognosis  is  worse  if  atony  be  secondary  to  gastroptosis. 
The  question  whether  atony  ever  passes  into  dilatation  is  at 
present  unsettled,  but  the  consensus  of  the  best  authorities 
is  that  while  such  an  outcome  is  possible,  it  is  extremely 
rare. 

Treatment. — Almost  without  exception  the  patients  are 
poorly  nourished  and  neurasthenic.  The  strictest  attention 
should  therefore  be  paid  to  the  general  health,  and  the  diet 
should  be  carefully  supervised.  As  gastric  acidity  is  nor- 
mal or  hyperacid  in  the  great  majority  of  instances,  a 
general  mixed  diet  is  allowable,  and  superalimentation  is 
to  be  advised,  although  care  should  be  exercised  that  the 
stomach  is  not  mechanically  overloaded  at  any  one  time. 
For  this  purpose  frequent  small  meals  are  indispensable, 
and  the  diet  should  be  as  dry  as  possible,  about  three  pints 
of  liquids  only  allowed  in  the  twenty-four  hours.  Milk 
may  be  badly  borne  by  these  patients,  so  that  its  administra- 
tion is  a  matter  of  personal  experiment.  Exercise  after 
meals  should  be  prohibited.  The  constipation  should  be 
treated  by  laxative  diet  and  by  enemata.  Cathartics  are 
to  be  absolutely  forbidden.     Lavage,  as  a  rule,  does  harm, 


410        MAXr.lL    OF  THE   PKACriCE    OF  MEDICINE. 

the  stomach  is  nicchanicalK-  tn-crdistcndcd  by  the  wash- 
water,  and  as  terincntation  and  retention  of  food  in  the 
fasting  stomach  do  not  occur  as  in  dilatation,  there  is  not 
the  same  necessity  for  washing  the  stomach.  Lavage 
should,  therefore,  be  only  employed  when  demanded  by 
other  complicating  lesions,  such  as  marked  mucous  gas- 
tritis, etc. 

Faradism  is  a  most  important  form  of  treatment,  and  is 
productix'e  of  great  improx'cmcnt  in  s\-nipt(jnis  and  in  tlie 
actual  atonic  condition.  It  ma\'  be  given  externally  or  by 
the  intragastric  method,  the  latter  being  far  preferable. 

In  the  external  method,  a  large  flat  electrode  is  placed 
over  the  twelfth  dorsal  vertebra  extending  to  the  left  of  the 
spine,  the  other  electrode  is  placed  over  the  epigastrium. 


Fig.  43. — The  author's  intragastric  electrode. 


Slowly  interrupted  currents  should  be  passed  as  strong  as 
comfort  will  allow  for  fifteen  minutes.  The  intragastric 
method  consists  in  the  passage  of  one  electrode  into  the 
stomach,  the  other  electrode  being  placed  o\-er  the  epigas- 
trium. The  intragastric  electrode,  modified  by  the  author 
from  the  instrument  of  Einhorn  (see  Fig.  43),  is  warmly 
recommended,  and  is  easy  of  introduction  even  in  the  most 
sensitive  patients.  From  fifteen  to  twenty  seances,  two  or 
three  times  a  week,  are  usually  sufficient  to  obtain  a  marked 
improvement.  If  toward  the  conclusion  of  the  seance  the 
abdominal  electrode  be  placed  at  various  spots  over  the 
colon,  much  good  is  done  to  the  accompanying  constipa- 
tion. 


DILATATION  OF   THE-  STOMACH ;    GASTKECTASIS.     4II 

DILATATION  OP  THE  STOMACH  ;   GASTRECTASIS. 

Etiology. — As  in  this  condition  the  stomach  is  unable  to 
empty  itself  of  its  contents,  three  causes  are  theoretically 
possible:  (i)  A  mechanical  obstruction  at  the  outlet;  (2) 
Muscular  weakness  of  the  organ  ;  (3)  A  paralytic  condition 
of  the  gastric  nerves.  While  there  are  cases  in  which 
rapidly  induced  muscular  weakness  and  paralytic  conditions 
are  directly  responsible  for  acute  dilatation  of  the  stomach, 
these  cases  are  exceedingly  rare.  The  occurrence  of  dilata- 
tion from  atonic  conditions,  the  so-called  "  primary "  or 
"atonic  dilatation,"  is  the  subject  at  present  of  great  dis- 
cussion, but  the  consensus  of  opinion  of  the  best  authorities 
is  that  while  atonic  dilatation  is  possible,  it  is  extremely 
rare,  and  that,  practically,  the  causes  for  a  dilated  stomach 
are  to  be  found  in  a  mechanical  narrowing  of  the  pyloric 
outlet. 

Mechanical  obstniction  may  be  intrinsic  or  extrinsic. 

Intrinsic  causes  are  cicatricial  contraction  following  ulcer 
of  the  pylorus  or  duodenum,  carcinoma,  hypertrophic 
thickening,  as  in  stenosing  gastritis,  and  congenital  narrow- 
ing of  the  pylorus.  Temporary  stenosis  occurs  with  pyloric 
spasm. 

Extrinsic  causes  embrace  kinking  of  the  duodenum,  as  in 
gastroptosis,  pressure  of  gall-stone  or  abdominal  tumor,  or 
the  traction  of  peritoneal  bands  and  adhesions. 

Patholog-y. — Whenever  obstruction  occurs  at  or  near 
the  pylorus  it  becomes  difficult  for  the  chyme  to  pass  from 
the  stomach.  This  difficulty  may  be  compensated  by 
hypertrophy  of  the  muscular  wall  of  the  stomach,  so  that 
no  actual  retention  of  food  occurs.  In  the  majority  of 
cases,  however,  there  is  no  compensation  and  food  is  retained, 
stagnates,  and  ferments.  The  continual  presence  of  residual 
food  within  the  stomach  and  the  pressure  of  gases  gener- 
ated by  the  fermentation  cause,  in  time,  an  actual  increase  in 
the  size  of  the  stomach.  It  is  a  misconception,  however, 
that  the  actual  size  of  the  stomach  is  essential  in  any  way. 
The  main  fact  is  that  the  fasting  stomach  cojitains  residual 
food  which  it  is  unable  to  expel — the  actual  size  of  the  stojn- 


412        MAXCAL    OF  THE   PRACTICE    OF  MEDICIXE. 

ach  is  tiitirilv  a  secondary  and  less  iiii/^or/anf  matter.  There 
are  cases  of  p\'loric  obstruction  in  which  the  size  of  the 
stomach  is  not  increased.  The  retention  k.^{  fermenting  food 
regularly  gi\-es  rise  to  a  chronic  gastritis. 

Symptoms. — The  symptoms  due  to  the  primary  cause 
precede  or  accompany  those  of  dilatation,  and  the  recogni- 
tion of  these  is  of  value  in  the  diagnosis.  Of  the  regular 
s)'mptoms  of  dilatation,  vomiting  is  the  most  characteristic. 
It  is  diagnostic  for  the  patient  habitually  to  vomit  food 
taken  the  da}'  previous.  According  to  the  size  of  the  stom- 
ach and  the  degree  of  pyloric  stenosis  the  stomach  will 
be  more  or  less  rapidly  overfilled  with  food  and  drink,  and 
the  consequent  disengorgement  leads  to  a  certain  periodicity 
in  the  vomiting.  For  the  characteristics  of  the  vomited 
matters  see  heading  of  "  Gastric  Analysis."  In  \ery  bad 
cases  the  stomach  may,  toward  the  close  of  the  disease,  lose 
its  contractile  power,  so  that  vomiting  ceases ;  this  sign  is  to 
be  regarded  as  of  serious  import.  Heart-burn  and  acid  eruc- 
tations are  frequent  from  the  fermentation  of  retained  un- 
digested food.  There  may  be  dragging  feelings  and  a  sense 
of  weight  from  the  mechanical  effects  of  the  dilatation. 
Pain  and  oppression  are  commonly  observed.  The  bowels 
are  usually  constipated,  although  attacks  of  colicky  pain 
and  diarrhoea  may  occur,  from  the  passage  of  the  acid  fer- 
menting food  into  the  intestine. 

If  stenosis  of  the  pylorus  is  marked,  little  food  or  fluid 
may  pass  the  obstruction.  In  consequence,  loss  of  flesh 
and  of  strength  become  apparent,  the  patient  is  unnaturally 
hungry  and  thirsty,  the  urine  becomes  diminished  in  quan- 
tity and  is  concentrated,  and  painful  cramps  of  the  muscles 
may  occur. 

Physical  Signs. — Tnspcction. — The  abdomen  is  large  and 
bulging,  and  the  position  of  the  greater  curvature  may  be 
seen.  In  cases  with  pyloric  stenosis  waves  of  peristalsis  or 
of  antiperistalsis  may  be  seen,  especially  in  cases  of  benign 
stenosis  of  considerable  duration. 

Palpation  often  reveals  the  peristalsis.  If  there  be  ste- 
nosis of  the  p}'lorus  from  simple  or  cancerous  thickening, 
the  mass  may  be  detected.     In  many  cases  the  boundaries 


DILATATION  OF   THE   STOMA C//;    GASTRECTASIS.     413 

of  the  stomach  may  be  appreciated,  the  feeHng  of  resistance 
being  compared  to  that  of  an  air-cushion.  Bimanual  palpa- 
tion may  elicit  splashing  sounds.  These  sounds,  which  are 
caused  by  the  shaking  together  of  air  and  water,  may  often 
be  elicited  in  a  healthy  stomach  after  eating.  To  be  of  any 
diagnostic  value,  the  splashing  sounds  should  be  produced 
when  the  normal  stomach  is  empty — two  hours  after 
drinking,  seven  hours  after  a  general  meal.  The  most  accu- 
rate means  for  determining  the  size  of  the  stomach  are  fur- 
nished by  inflation.  This  should  always  be  done  with 
caution,  and  never  to  an  extreme  degree,  especially  if  cancer 
or  ulcer  be  supposedly  present.  The  patient  may  be  given 
gr.  xx-oj  of  bicarbonate  of  sodium,  followed  by  an  equal 
amount  of  tartaric  acid  in  water,  and  the  inflated  stomach 
can  then  usually  be  felt  and  seen  distinctly.  A  stomach- 
tube  should  be  at  hand  for  the  withdrawal  of  the  gas 
should  unpleasant  symptoms  occur.  Another  method  is  by 
passing  a  stomach-tube  and  pumping  air  through  it  by  a 
Davidson  syringe.  The  introduction  of  a  stiff  tube,  so  that 
it  may  be  felt  along  the  greater  curvature,  is  an  accurate 
means  of  locating  the  lower  curvature,  but  is  not  altogether 
devoid  of  risk.  Electric  illumination  of  the  stomach,  or 
gastrodiaphany,  is  entirely  misleading. 

It  is  important  to  remember,  first,  that  many  cases  of 
pyloric  obstruction  exist  without  any  actual  increase  in  the 
size  of  the  stomach,  and,  second,  that  the  determination  of 
the  lower  border  in  an  abnormally  low  position  does  not 
mean  that  the  stomach  is  enlarged,  for  a  normal  sized 
stomach  may  be  displaced  downward  (see  Gastroptosis). 
To  be  sure  then  of  actual  dilatation  the  upper  curvature 
must  be  made  out  by  inflation  and  the  vertical  measure- 
ments must  be  greater  than  normal.  Third,  there  are  many 
stomachs  larger  than  others.  These  so-called  cases  of 
"  megalogastria  "  give  no  symptoms.  TJie  size  of  the  stoju- 
ach  is  unimportant  unless  at  the  same  time  there  be  food  re- 
te)ition  in  the  fasting  condition. 

Gastric  Analysis. — If  a  patient  be  given  the  Boas  supper 
at  night,  there  should  be  no  food-remains  in  the  fasting 
stomach  the  followinsf  morning.     It  is  otherwise  with  dila- 


414        M.tXrAI.    OF   THE   PRACTICE    OF  MEDICINE. 

tation  of  the  stomach.  On  passiiijj;  the  tube  food-remains  in  a 
fermenting  condition  are  removed,  often  in  large  quantities, 
and  are  often  composed  of  food  taken  a  long  time  previous, 
Tliis  fi)iding  of  food-remains  in  the  fasting  stomach  is  the 
most  positive  proof  of  dilatation,  and  this  procedure  should 
never  be  dispensed  with.  The  stomach  contents  differ  in  no 
wa)'  from  the  vomited  matters  ah'eady  alluded  to.  Upon 
standing  three  distinct  layers  are  to  be  distinguished,  an 
upper,  of  a  brownish  froth  ;  a  middle,  of  a  turbid  fluid ; 
and  an   under  layer  of  food  and  debris. 

The  clinical  analysis  of  benign  stenosis  (non-cancerous) 
differs  from  that  of  malignant  stenosis  (cancerous)  in  im- 
portant particulars,  and  is  of  the  greatest  service  in  diag- 
nosis. 

In  benign  stenosis  the  total  acidity  is  high,  hydrochloric 
acid  in  free  and  combined  form  is  present  in  increased 
quantity,  lactic  acid  is  absent.  Microscopically  are  to  be 
found  food-remains  in  a  fairly  digested  condition  without  the 
presence  of  meat-fibres. 

There  are  many  yeast-fungi  and  sarcinae  ventriculi.  A 
continual  presence  of  bile  bespeaks  a  stenosis  of  the  de- 
scending portion  of  the  duodenum  below  the  papilla. 

In  malignant  stenosis  the  acidity  is  high  from  the  presence 
of  fatty  acids  and  of  lactic  acid.  Hydrochloric  acid  is  not, 
as  a  rule,  present  in  a  free  state,  although  small  quantities 
of  combined  acid  are  usually  detected.  Microscopically 
food-remains  are  found,  meat-fibres  are  present,  yeast  and  a 
variety  of  bacteria  are  seen.  Sarcinae  are  not  present.  An 
especial  form  of  bacteria  is  the  Oppler-Boas  bacillus,  a  long 
non-motile  bacillus,  occurring  singly  or  in  long  jointed 
chains.  These  are  supposed  to  be  a  variety  of  lactic-acid 
bacilli,  and  are  almost  constantly  found  in  malignant  stenosis. 

When  carcinoma  develops  on  the  site  of  an  old  ulcer, 
hydrochloric  acid  is  usually  present  throughout  its  course 
in  excessive  amounts.  The  gastric  analysis,  resembling 
that  of  benign  stenosis,  together  with  the  presence  of  a 
tumor  and  a  cancerous  cachexia,  should  enable  a  correct 
diagnosis  to  be  made. 

Prognosis. — The  prognosis  of  malignant  stenosis  is  that 


DILATATION   OF   HIE   STOMACH;    GASIia-.CIASIS.     415 

of  cancer  of  the  stomach.  In  many  cases  of  benign  stenosis 
the  pyloric  lesion  remains  stationary  and  compensatory 
hypertrophy  of  the  stomach-wall  develops,  so  that  with 
care  and  treatment  the  patient  goes  along  in  comparative 
comfort.  In  other  cases  medical  treatment  is  simply  pal- 
liative, and  resort  must  be  had  to  surgical  interference,  the 
results  of  which  are  exceedingly  satisfactory. 

Treatment. — Attention  to  the  diet  is  of  the  first  import- 
ance, and  without  it  neither  a  cure  nor  an  improvement  can 
be  expected.  The  food  should  be  simple,  concentrated, 
and  easily  digested,  and  in  bad  cases  should  be  taken  in 
small  quantities  at  frequent  intervals.  Carbohydrates  and 
fatty  food  should  be  permitted  only  in  the  smallest  amount, 
and  liquids  are  to  be  partaken  of  sparingly.  In  advanced 
cases  a  resort  to  predigested  foods  and  peptones  for  short 
periods  is  often  of  service.  A  cup  of  hot  water  before 
meals  will  allay  excessive  thirst  more  effectively  than  a 
larger  amount  taken  with  or  after  the  meals.  To  relieve 
the  dilated  stomach  of  its  accumulated  contents  the  stomach 
should  be  emptied  and  then  be  washed  clean  with  warm 
water  or  with  weak  alkaline  solutions.  If  fermentation  be 
active,  a  i  per  cent,  solution  of  salicylic  acid  or  of  resorcin 
may  be  used.  Lavage  should  be  practised  the  last  thing 
at  night  or  early  in  the  morning,  and  it  should  be  repeated 
every  day  or  every  second  day,  according  to  the  require- 
ments of  the  case.  By  systematic  lavage  not  only  is  the 
weight  of  the  accumulated  food  removed,  but  the  stomach 
is  relieved  of  mucus  and  the  irritating  fatty  acids  of  ferment- 
ing food.  Strychnine  is  of  great  value,  through  its  power 
to  restore  tone  to  debilitated  muscular  fibre ;  it  is  of  special 
service  in  dilatation  not  depending  upon  pyloric  obstruc- 
tion^ Iron  and  tonics  are  indicated  to  restore  general  sys- 
temic tone. 

The  empirical  use  of  sweet  almond  oil  before  eating  (one- 
half  wineglassful)  has  apparently  been  of  great  service.  In 
benign  stenosis  the  added  element  of  a  possible  pyloric 
spasm  must  be  considered  and  treated  by  lavage,  gastric 
sedatives,  as  chloral,  bromide,  and  hyoscyamus,  and  by  the 
reduction  of  the  high  acidity  by  nitrate  of  silver  and  alka- 


410        .V.LVr.lL    OF   THE   PRACTICE    OF  MEDICEXE. 

line  powders  (see  Hyperacidity).  The  marked  improvement 
of  so  many  cases  by  lavage  is  to  be  explained  by  the  lessen- 
ing by  this  means  of  an  associated  pyloric  spasm. 

Intragastric  faradization  has  been  recommended.  Massage 
from  the  fundus  toward  the  pylorus  is  often  beneficial.  It 
should  be  cmplo\'ed  daily,  fi\'e  hours  after  the  principal 
meal.  If  there  be  bulging  of  the  epigastrium,  a  cushion,  a 
pad,  or  an  elastic  abdominal  bandage  should  be  worn. 

In  cases  of  marked  stenosis,  where  medical  means  fail, 
operative  procedures  are  indicated. 

The  pyloroplastic  operation  of  Mikulicz  has  been  fre- 
quently performed  with  benefit,  but  gastro-enterostomy,  by 
reason  of  its  greater  simplicity  and  in  perfection  of  stomach 
drainage,  would  seem  to  be  the  preferable  operation.  The 
results  of  operation  in  cases  of  pyloric  stenosis  are  often 
brilliant. 

ULCER  OF  THE   STOMACH. 

Etiology  and  Synonym.s. — Ulcer  of  the  stomach  is  found 
at  post-mortems  more  frequently  than  it  is  diagnosed  during 
the  life  of  the  patient,  evidences  of  present  or  past  ulceration 
being  found  in  5  per  cent,  of  persons  dying  from  all  causes, 
the  scars  being  the  more  common.  Females  are  more  fre- 
quently affected  than  males,  in  the  proportion  of  3  to  2. 
The  greatest  liability  is  between  the  ages  of  twenty  and 
forty  years  ;  but  the  disease  is  not  uncommon  up  to  the 
age  of  sixty,  especially  in  the  case  of  chronic  ulcers.  It  is 
more  common  in  ansemic  and  chlorotic  patients  and  those 
with  menstrual  disorders,  and  is  not  infrequently  associated 
with  tuberculosis.  It  occurs  especially  among  servant  girls 
and  in  shoemakers,  in  the  latter  case  being  consequent, 
possibly,  upon  pressure  on  the  stomach  while  at  work.  It 
is  not  as  common  in  America  as  in  Europe.  Synonyms : 
Peptic  ulcer;   Round  ulcer. 

Pathology .^ — There  is  but  one  ulcer  in  80  per  cent,  of  all 
cases,  but  as  many  as  thirty-four  ulcers  have  been  found. 
The  usual  situation  (86  per  cent.)  is  on  the  posterior  wall 
near  the  pylorus,  close  to  the  lesser  curvature.  The  ulcers 
vary  in  diameter  from  one-half  to  two  inches,  although  they 
may  be  much  larger.     The  usual  shape  is  round  or  oval, 


ULCER    OF  rilE   STOMACH.  417 

although  the  large  ulcers  are  apt  to  be  irregular,  and  several 
ulcers  may  coalesce  to  form  one  of  an  irregular  shape.  The 
ulcer  has  an  oblique  funnel  shape,  becoming  smaller  as  it 
extends  deeper,  the  successive  ulcerated  coats  being  dis- 
tinctly terraced.  The  floor  has  a  clean,  "  punched  out" 
appearance,  free  from  inflammatory  changes,  but  in  old  cases 
the  floor  and  walls  of  the  ulcer  may  be  indurated  and 
thickened.  The  depth  varies,  the  ulcer  sometimes  involving 
only  the  mucous  coat,  at  other  times  extending  to  the 
deeper  structures  and  even  perforating  the  stomach-wall. 
The  mucous  membrane  of  the  stomach  shows  almost  regu- 
larly the  lesions  of  a  subacute  or  chronic  catarrhal  gastritis. 
Changes  in  the  blood-vessels  of  the  stomach  have  been 
found  in  a  large  proportion  of  cases.  Among  these  changes 
may  be  mentioned  thrombosis  and  diffuse  endarteritis  of  the 
arteries  supplying  the  ulcerated  area.  Small  aneurysms 
have  been  found  in  the  floor  of  the  ulcer. 

Sequelae  and  Complications  of  Ulcer. — These  complica- 
tions are  of  the  utmost  importance. 

1.  The  ulcer  may  cicatrize.  In  some  cases  hardly  any 
scar  is  left ;  in  other  cases,  especially  if  extensive  ulceration 
of  the  muscular  coat  has  occurred,  considerable  puckering 
or  deformity  may  occur.  Cicatricial  stenosis  of  the  pylorus 
with  dilatation  of  the  stomach  is  a  not  infrequent  result.  It 
often  happens  that  large  ulcers  may  remain  open  for  years 
without  showing  signs  of  healing  (13-18  per  cent,  of  cases). 
These  chronic  ulcers  are  usually  situated  near  the  pylorus. 

2.  The  ulcer  may  perforate  the  wall  of  the  stomach. 
Gastric  contents  enter  the  peritoneum,  and  a  rapidly  fatal 
septicaemia  follows.  Perforation,  which  occurs  in  6  per 
cent,  of  all  cases,  is  more  common  with  ulcers  of  the  ante- 
rior than  with  those  of  the  posterior  walls  (in  the  proportion 
of  9  to  i). 

3.  Adhesions  may  form  between  the  stomach  and  the 
surrounding  viscera,  especially  the  left  lobe  of  the  liver,  the 
pancreas,  and  the  omental  tissues — Nature  "  putting  a  patch 
on  "  to  reinforce  the  weakened  spot  and  to  prevent  perfora- 
tion. These  adhesions  are  far  more  frequent  in  the  chronic 
than  in  the  acute  cases.     Extension  of  the  ulceration  and 

27 


41^5        .U.t.VL.lL    OF   THE   PKACJICK    OF  MEDICLXE. 

secondary  infection  by  pus  microbes  may  lead  to  fistulous 
tracts  and  suppurating;  ca\ities  in  these  adhering  organs. 
Gastro-intestinal  fistuhv  are  thus  lormed,  and  perforation 
into  the  pleura,  the  pericardium,  and  the  left  \entricle  of  the 
heart  has  been  known  to  occur.  The  suppurative  process 
may  extend  along  the  \eins,  causing  a  suppurative  p}'le- 
phlebitis  with  multiple  abscesses  in  the  liver.  The  adhe- 
sions may  not  be  extensive  enough  to  prevent  perforation, 
but  may  suffice  to  shut  the  site  of  rupture  from  the  general 
peritoneal  cavity,  so  that  a  localized  peritoneal  abscess 
results.  Perforation  of  the  posterior  wall  produces  an  air- 
containing  abscess  in  the  lesser  peritoneal  cavity,  known  as 
"  subphrenic  pyopneumothorax." 

4.  Erosion  of  a  blood-vessel  is  of  common  occurrence. 
This  accident  may  occur  with  recent  acute  ulcers,  but  it  is 
more  common  in  the  chronic  form  with  spreading  ulcera- 
tion. Ulcers  on  the  posterior  wall  of  the  stomach  may 
erode  the  splenic  artery  or  the  artery  of  the  lesser  curve. 

5.  In  5  or  6  per  cent,  of  cases  carcinoma  develops  on  the 
base  of  the  ulcer,  forming  the  so-called  ulcus  carcinoma- 
tosuni. 

Pathogenesis. — All  authorities  agree  that  gastric  ulcer 
results  from  self-digestion  of  part  of  the  stomach-wall  by  the 
gastric  juice.  Self-digestion  is  prevented  in  the  normal 
stomach  by  the  circulation  of  alkaline  blood  in  the  gastric 
mucous  membrane.  The  generally  accepted  theory  for 
ulcer  is  that  whenever,  for  any  reason,  the  circulation  stag- 
nates in  a  certain  area  of  the  stomach-wall,  and  its  nutrition 
fails,  the  part  is  acted  on  and  destroyed  by  the  gastric  juice, 
especially  if  it  possess  hypcrpeptic  powers.  Hyperacidity 
is  present  in  nearly  all  the  cases,  but  is  probabl\'  of  more 
importance  in  interfering  with  the  healing  of  the  ulcer  than 
in  causing  it,  for  it  has  been  proved  that  traumatic  lesions 
of  the  stomach  heal  rapidly  in  the  majority  of  instances, 
unless  there  be  at  the  same  time  considerable  hyperacidity, 
in  which  case  healing  is  delayed. 

Interference  with  the  circulation  of  a  part  of  the  stomach- 
wall  may  be  caused  in  a  variety  of  ways.  Experimental 
embolism  of  the  gastric  arteries  has  been  followed  by  ulcera- 


ULCER    OF   THE   STOMACH.  4I9 

tion,  and  this  experimental  evidence  accords  with  the  funnel 
shape  of  the  ulcer  and  with  the  actual  post-mortem  demon- 
stration of  an  embolus  or  a  thrombus  plugginj^  the  nutrient 
artery  in  some  cases.  This  is  also  demonstrated  by  the 
occurrence  of  multiple  acute  ulcerations  of  the  stomach  in 
acute  pyaemia.  Aside  from  these  cases,  however,  embolic 
ulceration  of  the  stomach  is  extremely  rare,  and  thrombosis 
of  the  gastric  artery  seldom  occurs  except  with  carcinoma. 
It  is  believed  that  the  gradual  obliteration  of  the  artery  by 
atheroma  is  one  of  the  principal  causes  for  chronic  ulcera- 
tion in  adult  cases.  The  common  occurrence  of  ulcer  with 
anaemia  and  chlorosis  is  to  be  explained  by  the  liability  to 
submucous  hemorrhages  and  the  high  gastric  acidity  so 
common  to  these  cases.  Local  pressure  or  traumatism  is 
supposed  to  act  locally  to  produce  changes  in  the  circula- 
tion. 

Talma  suggests  that  a  cramp-like  contraction  of  the  stom- 
ach, or  full  contents,  may  cause  such  pressure  on  the  arte- 
ries traversing  obliquely  the  muscular  coat  as  to  interfere 
with  the  circulation  and  to  allow  of  ulceration.  By  filling 
the  stomach  of  an  animal  with  gastric  juice  and  ligating  the 
orifices,  he  found  that  by  causing  firm  contractions  with 
faradism,  ulcer  resulted. 

Fenwick  has  lately  drawn  attention  to  the  occurrence  of 
solitary  glands  in  the  mucosa,  inflammation  of  which  may 
give  rise  to  ulceration  of  the  stomach,  and  which  can  assume 
the  characteristic  form  of  acute  perforating  ulcer. 

Symptoms. — There  may  be  any  or  all  of  the  symptoms 
of  chronic  gastritis.  These  dyspeptic  symptoms  may  be 
trifling  or  of  the  most  aggravated  character,  but  to  some 
extent  they  are  almost  invariably  present.  The  distinctive 
symptoms  are  pain  and  tenderness,  vomiting,  and  the  vom- 
iting of  blood. 

Pain  is  the  most  constant,  symptom.  The  characteristic 
pain  is  sharply  localized  in  the  epigastrium,  frequentl}^  run- 
ning through  to  the  back.  It  is  brought  on  by  eating,  usu- 
ally within  a  few  minutes,  and  it  is  aggravated  by  irritating 
food  or  by  an  excessive  quantity  of  food.  It  ceases  when 
the  stomach  is  relieved' of  its  contents  either  by  the  normal 


420        M.IXL.IL    OF  THE  PKACT/CI-:    OF  MFDICIXE. 

exit  of  food  throu<^h  the  pylorus  or  b>-  the  act  of  vomiting. 
The  pain  is  increased  by  exercise  and  is  diminished  by  rest. 
There  is  usually  a  localized  area  of  tenderness  an  inch 
or  so  below  the  ensiform  cartilage.  There  may  be,  how- 
ever, rehef  from  pressure  on  the  epigastrium.  There  is 
usually  an  area  of  cutaneous  h)'i)era;sthesia  in  the  epigas- 
trium or  left  h)'pochondrium,  over  which  stroking  of  the 
skin  is  painful.  Over  the  tenth  to  twelfth  dorsal  vertebrae, 
about  one  inch  to  the  left  of  the  median  line,  is  elicited  a 
tender  spot  in  about  one-third  of  the  cases.  When  present 
this  dorsal  point  is  very  characteristic.  In  many  ca.ses  this 
classical  pain  is  not  present,  variations  being  common. 

{(I)  In  some  cases  there  is  the  ordinar}^  pain  of  an  asso- 
ciated gastritis. 

(/;)  In  other  cases  the  pain  does  not  occur  until  two  or 
three  hours  after  eating  or  until  the  stomach  is  empty  ;  the 
pain,  being  due  to  hyperacidity,  is  relieved  by  food. 

(c)  In  some  cases  the  pain  comes  on  in  attacks  at  in- 
tervals for  weeks  or  months,  and  then  the  patient  goes  for 
a  long  time  without  attack*; ;  the  pains,  however,  return 
after  a  variable  length  of  time. 

{d)  In  other  cases  the  pain  is  reflected  to  the  nerves  of 
the  abdominal  wall  and  has  the  characters  of  a  neuralgia. 

Vomiting. — The  characteristic  of  the  vomiting  rests  not 
with  the  act  itself,  but  in  the  relief  it  gives  to  the  pain.  A 
pain  after  eating,  vomiting,  and  relief  is  the  regular  sequence. 

The  vomited  matters,  which  consist  of  undigested  food, 
usually  without  evidences  of  fermentation,  generally  contain 
HCl  in  more  than  the  normal  quantity. 

The  vomiting  with  ulcer  is  not  constant,  and  when  it 
does  occur  it  varies  greatly  in  severity,  some  patients  vom- 
iting nearly  everything  they  eat,  others  vomiting  but  sel- 
dom, if  at  all.  In  other  cases  the  vomiting  is  due  to  the 
associated  gastritis. 

Vomiting  of  blood  occurs  in  about  one-half  the  cases. 
The  vomiting  may  be  slight,  but  more  commonly  it  is  pro- 
fuse. If  profuse  and  sudden,  the  blood  raised  is  red,  partly 
clotted,  and  unaltered.  If  less  profuse,  it  may  be  retained 
in  the  stomach  for  a  longer  time,  so  that  by  alteration  by 


ULCER    O/'    TJIF.    S 70 A/AC//.  42 1 

the  gastric  juice  it  becomes  black  or  brown,  resembling 
"  coffee-grounds."  Repeated  hemorrhages  lead  to  a  high 
grade  of  ansemia ;  sudden  profuse  hemorrhage  may  cause 
death.  In  most  cases  some  blood,  and  in  rare  cases  all  the 
blood,  passes  the  pylorus  and  is  evacuated  with  the  stools, 
giving  them  a  black,  tarry  appearance.  On  adding  water  to 
these  stools  a  more  characteristic  blood-color  is  developed. 

In  old  ulcers  with  a  thickened  base  an  indurated  mass 
may  be  felt  on  examination  in  the  neighborhood  of  the 
pylorus.  In  these  cases  the  symptons  of  dilatation  of  the 
stomach  may  be  present. 

Hysterical  and  anaemic  symptoms  are  often  present ;  fre- 
quently they  may  so  overshadow  the  symptoms  of  the  ulcer 
that  the  latter  condition  is  overlooked. 

Varieties  in  Clinical  Course. —  i.  In  some  cases  the  dis- 
ease runs  a  latent  course  and  is  found  after  death  from  some 
other  disease,  without  having  given  symptoms  during  life. 

2.  Some  cases  run  a  latent  course  until  there  occurs  a 
profuse  hemorrhage  which  may  terminate  fatally  or  which 
may  be  followed  by  the  symptoms  of  chronic  ulcer. 

3.  With  or  without  a  brief  history  of  gastric  disturbance, 
sudden  perforation  occurs,  causing  speedy  death. 

4.  In  some  cases  the  characteristic  symptoms  are  not 
marked,  but  resemble  those  of  chronic  gastritis,  so  that  a 
diagnosis  cannot  with  certainty  be  made. 

5.  In  some  patients  the  disease  shows  periods  of  appar- 
ent cure,  after  which  there  is  a  return  of  the  symptoms. 
It  is  hard  to  say  whether  fresh  ulcers  form  or  whether  the 
cicatrix  of  an  old  ulcer  becomes  ulcerated. 

6.  In  some  cases  the  anaemia  and  cachexia  from  malnu- 
trition become  so  marked  as  to  suggest  pernicious  anaemia 
or  cancer. 

7.  In  other  cases  the  symptoms  of  pyloric  stenosis  and 
secondary  dilatation  of  the  stomach  are  so  marked  that  the 
symptoms  of  the  primary  ulcer  are  overlooked. 

The  prognosis  is  uncertain,  as  a  fatal  hemorrhage  or 
perforation  may  occur  at  any  time.  The  possibility  of 
fistulae  and  suppuration  without  the  stomach,  as  noted 
under   the    heading    of   "  Pathology,"    should    be    kept    in 


4::-:      m.i.\l:il  of  tj/e  practice  of  medicexe. 

mind.  The  duration  of  the  disease  varies  tVoni  a  {cw 
months  to  a  number  o{  years,  the  average  beiny;  from  three 
to  five  years.  Relapses  are  frequent.  Reeent  ulcers  are 
more  amenable  to  treatment  than  old,  indurated  ulcers. 
The  older  statistics  are  :  death  from  hemorrhage  occurs  in 
4  per  cent,  of  all  cases;  from  perforation,  in  6.5  per  cent. 
About  15  per  cent,  of  all  cases  of  ulcer  of  the  stomach  are 
said  to  be  fatal,  but  this  seems  altogether  too  high  a  per- 
centage. 

Under  modern  treatment  the  statistics  are  much  better. 
Leube  reports  556  cases,  with  a  mortality  of  2.4  per  cent.; 
I  per  cent,  died  of  hemorrhage  ;  I  per  cent,  of  perforation. 
Under  treatment  79  per  cent,  were  permanently  cured  in  four 
or  five  weeks;  20  per  cent,  improved,  but  were  not  perma- 
nently cured;  i^  per  cent,  only  were  unimproved.  The 
general  mortality  from  other  sources  has  been  reduced  to 
about  4  per  cent. 

It  is  often  hard  to  tell  when  the  s)-mptoms  of  ulcer  end,  as 
gastritis,  neuralgia,  or  dilatation  of  the  stomach  due  to  the 
presence  of  the  cicatrix  may  continue  gastric  symptoms. 

Treatment. — The  secret  of  treatment  is  to  reduce  gastric 
acidity  and  to  give  the  stomach  as  much  of  a  rest  as  possi- 
ble. When  the  diagnosis  is  made,  absolute  rest  in  bed 
should  be  enforced  until  acute  symptoms  have  subsided. 
The  following  modification  of  Lcube's  treatment  in  these 
cases  is  advised  :  The  patient  should  be  kept  absolutely  at 
rest  in  bed,  and  for  three  days  should  be  nourished  entirely 
by  rectum.  Small  quantities  of  aerated  water  ma)' be  taken 
to  assuage  thirst.  Hot  poultices  should  be  applied  to  the 
epigastrium.  At  the  end  of  three  days  the  poultices  may  be 
discontinued,  and  applications  of  w^et  flannel  covered  by 
oiled  silk  and  changed  every  six  hours,  may  be  substituted, 
and  should  be  continued  for  four  weeks.  From  the  third 
to  seventh  day  the  diet  should  consist  of  6  07..  of  equal 
parts  milk  and  lime-water  every  two  hours,  and  rectal 
alimentation  continued.  During  the  second  week,  7  oz.  of 
milk  and  i  oz.  of  lime-water  are  to  be  given  every  two 
hours,  with  custards  and  vegetable  puree,  rectal  alimenta- 
tion discontinued.     During  the  third  week,  farinaceous  pud- 


ULCER    OF   THE   STOMACH.  423 

dings,  crackers,  toast,  zwieback,  sweetbreads,  baked  potatoes, 
and  fish  may  be  added.  During  the  fourth  week,  birds  and 
fowl  may  be  taken,  in  addition  to  simple  vegetables  without 
much  vegetable  fibre.  For  some  time  the  patient  should 
avoid  raw  fruit,  very  hot  and  very  cold  drinks,  and  all  stimu- 
lating and  highly  seasoned  food. 

Nitrate  of  silver  may  be  given  after  the  third  day.  The 
patient  receives  |-  gr.  three  times  a  day  for  three  days,  \  gr. 
t.i.d.  for  three  days,  and  -f  gr.  t.i.d.  for  three  days.  The 
cycle  is  then  recommended  and  continued  throughout  the 
four  weeks.  During  this  treatment  of  silver,  diarrhoea  may 
set  in,  necessitating  the  administration  of  bismuth  or  the 
discontinuance  of  the  drug.  If  nitrate  of  silver  is  not  well 
borne,  a  glass  of  hot  Carlsbad  water  morning  and  night 
may  be  serviceable. 

Under  this  treatment  pain,  vomiting,  and  tenderness 
rapidly  subside,  and  the  results  are  permanent  in  80  per 
cent,  of  cases.  When  patients  cannot  take  the  rest-treat- 
ment, the  results  are  not  as  satisfactory.  The  diet  should 
be  on  the  lines  indicated,  and  the  medicinal  treatment  is 
the  same.  Large  quantities  of  subcarbonate  of  bismuth 
may  be  given  in  the  fasting  condition  once  or  twice  a  day 
(oiij  in  .Ivj  of  water). 

Lavage  is  contraindicated  except  in  long-continued  cases 
with  pyloric  obstruction. 

Hsematemesis  is  to  be  treated  with  absolute  rest  and  quiet 
of  body  and  mind  and  by  the  giving  of  cracked  ice.  The 
patient  should  be  put  as  rapidly  as  possible  under  the  influ- 
ence of  opium,  preferably  by  hypodermics.  Drugs  by  the 
mouth,  such  as  gallic  acid,  ergot,  and  acetate  of  lead,  are 
of  no  service,  and  the  efficacy  of  local  applications  of  ice 
is  doubtful.  Stimulation  should  be  moderate,  as  a  depressed 
state  of  the  circulation  is  nature's  method  of  checking  hem- 
orrhage by  allowing  the  formation  of  a  thrombus. 

After  hemorrhage  all  food  should  be  withheld  from  the 
stomach  for  several  days. 

Anaemic  and  cachectic  conditions  should  be  treated 
steadily  and  persistently  by  iron,  arsenic,  good  fresh  air, 
and  a  change  of  climate  or   of  occupation  if  necessar}\ 


424        M.IXr.lI.    OF   THE    PRACTICE    OF  MEDICIXE. 

S\.W'^\c\x\  interference  is  indicated  in  the  following  condi- 
tions : 

1.  In  repeated  uncontrollable  hemorrhajj^e. 

2.  When  severe  pain  and  repeated  vomiting  persist  after 
medical  treatment  and  diet. 

3.  When  the  ulcer  perforates. 

4.  When  cicatricial  p}'loric  stenosis  occurs. 

For  ixirticulars  the  reader  is  referred  to  special  works  on 
Surgery. 

CANCER    OF    THE    STOMACH. 

Etiology. — Next  to  the  uterus,  the  stomach  is  the  most 
frequent  seat  of  primary  cancer,  the  organ  being  involved  in 
21.4  per  cen:.  of  a  total  of  over  30,000  cases.  According  to 
Welch,  cancer  of  the  stomach  is  the  cause  of  death  in  i  per 
cent,  of  all  persons  d}'ing  after  the  age  of  twenty  years.  It 
is  almost  always  primary.  The  actual  cause  of  cancer  of  the 
stomach  is  not  understood.  It  occurs  in  men  a  little  more  fre- 
quently than  in  women,  and  it  is  more  common  in  some  races 
than  in  others,  pure-blooded  negroes  being  comparatively  ex- 
empt. Three-fourths  of  all  cases  occur  between  the  fortieth 
and  seventieth  years,  but  the  occurrence  of  cancer  between 
the  ages  of  twenty-five  and  forty  is  not  as  exceptional  as  is 
often  represented.  The  influence  of  heredity  is  seen  in  14 
percent,  of  all  cases.  Chronic  gastritis  has  preceded  cancer 
in  a  fair  number  of  cases,  and  carcinomatous  changes  in 
the  wall  of  an  old  gastric  ulcer  have  been  described. 

Pathology. — The  varieties  met  with,  in  the  order  of  fre- 
quency, are  cylindrical-celled  epithelioma,  encephaloid,  scir- 
rhous, and  colloid  cancer.  According  to  Welch,  the  pyloric 
region  is  involved  in  60.8  per  cent.,  the  lesser  curvature  in 
1 1.4  per  cent.,  the  cardiac  end  in  8  per  cent,  the  posterior 
wall  in  5.2  per  cent.,  the  whole  or  the  quarter  part  of  the 
stomach  in  4.7  per  cent.,  multiple  tumors  3.5  per  cent., 
greater  curvature  in  2.6  per  cent.,  anterior  wall  in  2.3  per 
cent.,  fundus  in   1.5  per  cent. 

Cancer  begins  in  the  mucous  membrane  of  the  stomach 
and  grows  in  all  directions.  The  portion  of  the  growth 
projecting  into  the  cavity  of  the  stomach  may  be  broad  and 


CANCER    OF   THE   STOMACH.  425 

flat  or  cauliflower-like,  or  ulceration  may  occur,  allowing 
of  hemorrhage  or  of  perforation.  Perforation  into  the  peri- 
toneum occurs  in  4  per  cent,  of  all  cases,  being  usually  pre- 
vented by  the  formation  of  adhesions  between  the  stomach 
and  adjacent  structures.  More  rarely  perforation  occurs 
into  the  colon  or  through  the  abdominal  wall,  or  fistulae 
may  be  formed  into  the  lungs,  the  pleura,  and  the  small 
intestine.  Ulceration  is  most  common  with  encephaloid 
and  cylindrical-celled  epithelioma,  less  frequently  in  scir- 
rhous and  colloid  cancer.  Growths  about  the  pylorus  are 
apt  to  cause  pyloric  stenosis  with  secondary  dilatation  of 
the  stomach.  Growths  in  the  cardia  are  apt  to  cause  stenosis 
and  secondary  dilatation  of  the  oesophagus.  Chronic  catar- 
rhal gastritis  almost  invariably  occurs  with  the  growth  of 
cancer. 

Encephaloid  cancer  grows  rapidly  and  forms  cauliflower- 
like masses  projecting  into  the  cavity  of  the  stomach,  tend- 
ing to  ulcerate  easily.  It  is  soft,  of  a  grayish-white  or 
reddish-white  color,  and  contains  much  blood.  Micro- 
scopically the  growth  consists  of  a  scanty  stroma  enclosing 
alveoli  filled  with  irregular  polyhedral  and  cylindrical  cells. 
Metastases  are  common. 

Cylindrical-celled  epithelioma  somewhat  resembles  the 
encephaloid,  but  is  firmer,  especially  at  the  edges.  It  is 
prone  to  ulcerate  and  to  form  metastases.  Cysts  contain- 
ing mucus  are  often  found.  This  form  of  tumor  consists  of 
elongated  tubular  spaces  filled  with  columnar  epithelium 
with  an  abundant  stroma,  and  it  resembles  the  structure 
of  tubular  glands. 

Scirrhous  cancer  may  occur  as  a  hard,  circumscribed 
tumor  or  as  a  diffused  thickening  of  the  gastric  wall.  It 
is  hard  to  the  feel,  and  it  is  most  often  found  at  the  pylorus, 
causing  stenosis.  Scirrhus  has  but  little  tendency  to  ulcer- 
ate. It  consists  of  a  hard  fibrous  stroma  with  relatively  few 
and  small  alveoli. 

Colloid  cancer  shows  itself  as  an  extensive  uniform  infil- 
tration and  thickening  of  all  the  layers  of  the  wall  of  the 
stomach.  It  spreads  with  great  frequency  to  involve  adja- 
cent structures,  although  actual  metastasis  is  comparatively 


426        MA.VrAL    OF   THE   PRACTICE    OF  MEDICINE. 

rare.  It  shows  trabecuKx'  of  connective  tissue  enclosing 
large  alveoli  filled  with  translucent  colloid  niateri.il.  To 
this  variety  the  name  of  "  alveolar  cancer  "  has  been  ap- 
plied. 

These  varieties  are  often  mixed  in  the  same  specimen,  so 
that  it  is  hard  to  say  in  what  class  the  growth  is  to  be  placed. 

Secondary  cancerous  growths  occur  by  (i)  direct  exten- 
sion, involving  the  oesophagus  or  any  structure  to  which 
the  stomach  may  become  adherent,  or  by  (2)  metastasis. 
This  latter  is  most  frequent  in  the  lymphatic  glands  in  the 
neighborhood  of  the  stomach  ;  next  in  frequency  in  the 
liver,  the  peritoneum,  the  omentum,  and  the  intestines;  less 
frequently  in  the  pleura  and  the  lungs.  The  liver  is  involved 
in  about  one-third  of  all  cases.  The  cervical  and  inguinal 
lymphatic  glands  are  not  infrequent]}^  involved,  and  occa- 
sionall}'  growths  occur  subcutaneously  near  or  at  the  navel. 

The  symptoms  of  cancer  of  the  stomach  may  be  de- 
scribed as  gastric,  constitutional,  and  those  due  to  the  sec- 
ondary growths. 

Gastric  Symptoms. — {a)  As  chronic  gastritis  almost  inva- 
riably accompanies  cancer  of  the  stomach,  it  gives  rise  to 
any  or  all  of  its  regular  symptoms.  The  appetite  is  usually 
more  completely  lost  than  in  uncomplicated  gastritis. 

{b)  Pain  occurs  in  92  per  cent,  of  all  cases,  being  rarely 
absent  except  in  old  people.  The  pain  is  severe,  more  or 
less  continuous,  and  is  described  as  burning,  gnawing,  or 
neuralgic.  It  may  be  referred  to  the  epigastrium  or  be- 
tween the  scapulae,  but  the  locality  of  the  pain  is  no  indi- 
cation of  the  seat  of  the  growth.  Pain  is  usually  increased 
by  eating,  although  this  may  not  be  evident  until  some  little 
time  after  taking  food. 

The  pain  differs  from  the  typical  pain  of  ulcer  (i)  in  be- 
ing more  continuous,  so  that  the  patient  is  often  awakened 
at  night  by  it;  (2)  in  being  less  dependent  on  food;  (3)  in 
the  increased  pain  being  delayed  some  little  time  after  tak- 
ing food  ;  (4)  in  being  less  sharply  localized ;  and  (5)  in  not 
usually  being  relieved  by  vomiting.  There  is  generally  ten- 
derness on  pressure  over  the  growth,  but  the  tenderness  is 
less  marked  and  less  sharply  localized  than  in  ulcer. 


CANCER    OF    rilF.    STOMACIL  427 

{c)  Vomitini^  occurs  in  from  80  to  88  per  cent,  of  all 
cases.  As  a  rule,  it  does  not  appear  until  the  latter  part 
of  the  disease,  when  the  cancer  has  attained  a  considerable 
size,  whereas  the  vomiting  of  ulcer  comes  on  early.  Vom- 
iting is  more  frequent  if  either  orifice  be  involved.  If  the 
pylorus  be  affected,  vomiting  occurs  longer  after  eating 
than  if  the  cardiac  orifice  be  involved,  the  food  often  re- 
maining for  some  hours  in  the  stomach  without  being 
digested.  There  are  cases,  however,  in  which  vomiting  is 
an  early  and  a  distressing  symptom,  severe  enough  to  cause 
a  fatal  termination.  If  the  stomach  be  dilated,  the  vomit- 
ing may  be  typical  of  that  condition.  The  vomited  matters 
consist  of  undigested  food,  often  fermenting  and  mixed  with 
mucus.  Fragments  of  ulcerating  growths  may  be  found, 
establishing  a  diagnosis.  These  fragments,  however,  are 
more  frequently  found  in  the  washing  out  of  the  stomach. 

{d)  Hemorrhages. — It  is  important  to  distinguish  between 
the  slight  and  the  copious  hemorrhage  of  gastric  cancer. 
An  admixture  of  a  small  quantity  of  blood  with  the  vomit 
is  present  in  about  half  the  cases.  The  blood  is  brown  or 
black,  resembling  coffee-grounds,  the  normal  pigment  hav- 
ing been  converted  by  the  acids  of  the  stomach  into  dark- 
brown  haematin. 

Copious  hemorrhages  occur  in  about  one-eighth  of  the 
cases.  The  blood  may  be  bright  red  or  more  or  less  dark- 
ened, according  to  the  length  of  time  it  has  been  retained 
in  the  stomach.  Following  profuse  haematemesis  some 
black  tarry  blood  is  usually  passed  with  the  stools. 

Hemorrhage  in  cancer  differs  from  that  in  ulcer  (i)  in 
being  more  frequent ;  (2)  in  being  usually  less  copious  ;  (3) 
in  being  retained  longer  in  the  stomach,  with  the  conse- 
quent "coffee-ground"  appearance;  and  (4)  in  occurring  in 
the  later  stages,  when  the  cancer  is  ulcerating  and  the 
patient  is  emaciated  and  cachectic,  whereas  in  ulcer  the 
hemorrhage  is  an  early  symptom,  occurring  when  the 
patient  is  apparently  in  good  health. 

(t')  If  dilatation  of  the  stomach  or  stenosis  of  the  cardiac 
end  of  the  oesophagus  complicate,  the  symptoms  of  these 
conditions  will  be  added. 


428        .VAXr.lL    OF   THE    PRACTICE    OF  MEDICIXE. 

Constitutional  Symptoms. — The  patient  grows  progres- 
sively anaemic,  developing  a  waxy  or  "beeswax"  pallor 
which  is  quite  characteristic ;  emaciation  and  prostration 
become  more  and  more  marked ;  there  may  be  a  slight 
irregular  rise  in  the  afternoon  temperature.  Slight  oedema 
of  the  ankles  is  common,  and  a  general  itching  of  the  skin 
is  complained  of — a  symptom  which  in  old  people  should 
suggest  cancer  or  diabetes.  In  rare  cases  chills  with  par- 
oxysmal elevations  in  temperature  ha\e  been  recorded. 
Delirium  or  coma  may  occur  as  a  terminal  event. 

Symptouis  of  tJic  sccondaiy  grozi't/is  vary  according  to 
their  size  and  location.  Metastases  in  the  liver  cause  a 
general  enlargement  of  that  organ,  with  pain,  tenderness, 
and  jaundice.  Ascites  is  not  uncommon.  Involvement 
of  the  peritoneum  and  the  omentum  gives  rise  to  ascites 
and  abdominal  pain  and  tenderness,  and  on  examination 
the  thickened  masses  may  be  evident.  The  glands  above 
the  clavicle  are  often  enlarged.  The  subcutaneous  nodules 
near  the  umbilicus  have  been  alluded  to. 

Gastric  Analysis. — Two  distinct  sets  of  cases  are  en- 
countered :  one  of  the  ordinary'  cases,  the  other  of  ulcus 
carcinomatosum. 

I.  In  ordinary  cases  free  HCl  is  usually  absent  (87  per 
cent.),  although  small  quantities  of  the  combined  acid  may 
be  encountered.  Lactic  acid  is  usually  present  in  sufficient 
quantities  to  give  a  decided  reaction  to  Ufflemann's  test. 
In  doubtful  cases  the  stomach  should  be  washed  the  night 
before  the  test-breakfast,  and  no  milk  should  be  allowed  for 
the  twenty-four  hours  previous  to  the  examination.  In 
almost  all  cases  there  is  a  decided  loss  of  the  motor  power 
of  the  stomach,  as  shown  by  the  presence  of  food-remains 
in  the  fasting  state.  The  loss  of  motility  is  not,  as  a 
rule,  accompanied  by  any  increase  in  the  actual  size  of  the 
stomach,  unless  the  growth  obstruct  the  pylorus,  in  which 
case  dilatation  may  occur,  although  usually  to  a  very  mod- 
erate degree.  Cancer  of  the  stomach  is  almost  certainly 
present  when  (i)  HCl  is  absent.  (2)  lactic  acid  is  present, 
and  (3)   stagnation    of  food    in   the  stomach   occurs.     The 


CANCER    0/<    TJIE   STOAIACJf.  429 

diagnosis  is  more  uncertain  if  only  two  of  the  three  condi- 
tions are  present. 

Microscopically  are  usually  found  food-remains,  the  meat 
fibres  showing  deficient  digestion,  yeast  fungi,  and  very 
rarely  sarcinas.  The  Oppler-Boas  bacilli  are  almost  always 
found,  and  occur  as  long,  non-motile  rods  joining  each 
other  at  an  acute  angle.  They  occur  in  stagnating  gastric 
contents  with  the  presence  of  lactic  and  the  absence  of 
hydrochloric  acid,  and  possess  considerable  diagnostic 
value,  as  these  conditions  are  present  almost  exclusively 
in  gastric  cancer. 

2.  In  ulcus  carci)iomatosuni  HCl  is  usually  present  in  nor- 
mal or  increased  quantity,  together  with  lactic  acid  and  food 
stagnation.  Such  gastric  analysis,  with  the  clinical  history 
of  cancer  and  the  presence  of  cancerous  cachexia,  should 
make  the  diagnosis  positive. 

Physical  Examination. — Owing  to  the  position  of  the 
stomach,  only  tumors  of  the  pylorus,  of  the  anterior  wall, 
and  of  a  large  part  of  the  greater  curvature  are  accessible 
to  examination.  Tumors  of  the  fundus,  of  the  posterior 
wall,  and  of  the  greater  part  of  the  lesser  curvature  cannot 
be  detected  unless  of  some  considerable  size  or  unless  the 
stomach  be  displaced  downward.  Tumors  of  the  cardiac 
end  cannot  be  detected  at  all. 

As  the  growth  is  usually  at  or  near  the  pylorus,  the 
tumor  is  in  most  cases  felt  in  the  epigastric  region  as  a 
firm,  hard,  nodular  mass,  tender  on  pressure.  It  is  not  in- 
fluenced by  respiration  unless  adhesions  with  the  liver  are 
present.  Owing  to  the  weight  of  the  growth  dragging  the 
pylorus  downward,  the  tumor  may  be  felt  as  low  down  as 
the  iliac  region.  A  definite  tumor  is  felt  in  80  per  cent,  of 
all  cases.  Examination  may  be  made  with  the  patient  lying 
down,  with  the  knees  drawn  up  so  as  to  relax  the  abdominal 
wall ;  in  doubtful  cases  examination  in  the  knee-chest 
position  may  be  more  satisfactory.  Inflation  of  the  stom- 
ach with  gas  (see  Dilatation  of  the  Stomach)  may  be  re- 
sorted to ;  this  procedure  frequently  brings  the  tumor 
into  reach.  In  cases  of  colloid  cancer  no  regular  tumor- 
mass   may  be  felt,  but  the  stomach-wall   feels  abnormally 


430        MAXrJI.    OF   THE   PRACTICE    OE  MEDICIXE. 

thick  and  resistant.     It  is  rare  to  feel  a  tumor   before  the 
third  to  the  sixth  month  of  the  disease. 

Peculiarities  in  the  Clinical  Course. —  i.  Some  cases 
run  a  latent  course,  death  resulting  from  some  intercurrent 
disease.     This  occurs  especially  in  aged  subjects. 

2.  In  some  cases  gastric  symptoms  may  be  insignificant, 
while  anaemic  and  cachectic  symptoms  are  marked.  These 
cases  are  often  diagnosed  as  pernicious  anaemia  or  Bright's 
disease.  The  blood  count  is  rarely  if  ever  below  i,ooo,000, 
as  in  pernicious  anaemia. 

3.  In  other  cases  gastric  symptoms  are  developed,  but 
are  not  characteristic.  These  cases  are  often  diagnosed  as 
chronic  gastritis  or  dilatation. 

4.  There  are  cases  in  which  the  symptoms  of  the  primary 
gastric  cancer  are  obscured  by  symptoms  arising  from  the 
secondary  growths.  These  cases  are  then  diagnosed  as 
primary  cancer  of  the  liver  or  of  the  peritoneum. 

The  prog-nosis  is  practically  hopeless.  The  duration  of 
the  disease  is  usually  about  two  years.  Cases  live  about 
one  year  after  the  diagnosis  is  made.  Occasionally  may 
be  seen  cases  with  a  rapid  course  terminating  in  from  three 
to  six  months. 

Treatment. — If  the  growth  be  localized  and  non-adhe- 
rent to  other  structures,  and  if  no  secondary  deposits  are 
present,  surgical  interference  may  be  justifiable.  Resection 
may  be  performed,  although  the  results  as  yet  are  far 
from  encouraging.  W'hen  stenosis  of  the  pylorus  exists, 
gastro-enterostom)'  may  be  advised,  to  drain  the  stom- 
ach. An  improvement  usually  occurs  in  the  subjective 
symptoms,  although  there  is  no  effect  upon  the  actual 
progress  of  the  lesion.  Medicinal  treatment,  on  the 
other  hand,  is  merely  palliative.  Condurango  at  one  time 
was  lauded  as  a  specific,  but  it  is  now  recognized  only 
as  an  excellent  stomachic  tonic,  in  some  cases  relieving  the 
pain  and  the  vomiting.  It  may  be  given  as  a  decoction,  a 
wine,  or  a  fluid  e.xtract.  Hydrochloric  acid  is  indicated  as 
an  aid  to  digestion,  and  it  is  usually  of  service.  The  pain 
and  the  vomiting  are  to  be  controlled  on  general  principles 
of  treatment.     As  the  disease  is  certainly  fatal,  there  can 


G/1S  TR  OP  TOSIS.  43  I 

be  no  objection  to  giving  opium,  as  it  makes  no  difference 
whether  or  not  the  habit  is  formed. 

NON-CANCEROUS   TUMORS   OF  THE    STOMACH.^ 
These  growths  are  rare  and  are  not  causative  of  destruc- 
tive symptoms. 

Polypi  are  the  most  common  form.  They  are  composed 
of  hypertrophied  mucous  membrane,  are  rarely  larger  than 
a  bean,  and  are  usually  multiple. 

Sarcomata  are  rare.  Fibromata  and  lipomata  are  occa- 
sionally met  with.  Lymphoniata  may  be  found  in  connec- 
tion with  leukaemia  or  pseudo-leukaemia.  Myoinata  or  Jib ro- 
viyomata  may  occur  in  the  form  of  large  polypi.  Cases  of 
foreign  bodies  have  often  been  mistaken  for  tumors.  The 
most  remarkable  instances  are  the  hair  balls  in  hysterical 
women  who  are  in  the  habit  of  eating  their  own  hair. 

GASTROPTOSIS. 

By  this  term  is  meant  a  sinking  downward  of  the  entire 
stomach,  which  assumes  a  vertical  position  without  any 
change  in  the  actual  size  of  the  organ.  It  is  usually  asso- 
ciated with  a  similar  displacement  of  the  small  intestine 
{e7iteroptosis),  of  the  large  intestine  {coloptosis),  and  of  the 
right  kidney  {nephroptosis).  To  the  downward  displace- 
ment of  all  of  the  abdominal  viscera,  the  term  "  splanch- 
noptosis "  has  been  applied. 

Patholog-y. — There  is  a  downward  displacement  of  the 
stomach  with  laxity  or  lengthening  of  the  supporting  liga- 
ments. In  some  instances  the  stomach  is  retained  in  its 
faulty  position  by  adhesion. 

Etiolog-y. — In  some  cases  there  is  a  congenital  weakness 
of  the  gastro-hepatic  omentum,  to  which  there  seems  to  be 
a  family  predisposition.  Tight  lacing  and  weakness  of  the 
abdominal  wall,  such  as  occurs  after  repeated  pregnancies, 
are  common  causes.  In  rare  cases  the  stomach  is  drawn 
down  by  contracting  adhesions.  Chlorosis  seems  to  be  an 
important  predisposing  cause.  In  some  cases  the  condition 
develops  after  sudden  loss  of  flesh.     Gastroptosis  is  far  more 


43-         .V.I.VC.I/-    OF    THE    PRACTICE    OF  MEDICIXE. 

common  in  women  than  in^nicn,  and  the  s}'mptoms  usually 
appear  during  adult  life. 

Symptoms. — There  are  no  characteristic  symptoms,  and 
the  condition  may  run  a  latent  course,  revealing  itself  only 
by  a  routine  examination.  In  other  cases  symptoms  are 
present  and  usually  follow  one  of  two  clinical  types. 

1.  The  condition  may  remain  latent  for  many  years  and 
then,  usually  after  physical  or  mental  strain,  symptoms  of  a 
neurotic  nature  develop,  such  as  hx'peraesthesia,  hyperacidity, 
or  p)'loric  spasm  (see  Gastric  Neuroses).  With  the  local 
neuroses  appear  any  of  the  symptoms  of  a  general  neu- 
rasthenia. In  these  cases  the  symptoms  are  usuall}^  inter- 
mittent, and  depend  largely  upon  the  general  condition  of 
the  patient. 

2.  In  other  cases  gastric  atony  develops,  gastroptosis 
being  the  most  common  cause  for  this  condition.  The 
symptoms  of  atony  are  well  marked,  gastric  neuroses  of 
any  type  are  present,  and,  with  rare  exceptions,  the  patients 
are  profoundl}'  neurasthenic. 

Hyperacidit}',  constipation,  and  flatulence  are  prominent 
s)-mptoms.  In  these  cases  the  symptoms  are  more  or  less 
constant. 

In  either  type  gastritis  may  occur  as  a  complication,  but 
very  rarely  is  it  sev^ere.  Dilatation  of  the  stomach  may 
occur  with  gastroptosis  in  one  of  three  ways  :  {ci)  there  may 
be  kinking  at  the  duodenal  angle ;  [b)  there  may  be  pyloric 
spasm,  to  which  the  gastric  hyperaesthesia  and  hyperacidity, 
so  common  in  gastroptosis,  predispose ;  (r)  there  may  be 
downward  traction  of  the  mesentery  from  an  associated 
enteroptosis,  so  that  the  superior  mesenteric  vessels  and 
roots  of  the  mesentery  press  like  a  cord  upon  the  junction 
of  the  duodenum  and  jejunum.  To  this  form  of  obstruc- 
tion the  term  "  arterio-mesentcric  constriction"  lias  been 
applied. 

Diag-nosis  is  made  by  finding  the  greater  curvature 
below  the  umbilicus,  if  at  the  same  time  dilatation  can  be 
excluded.  The  fact  that  the  stomach  is  free  from  food- 
remains  in  a  fasting  state  is  sufficient  to  exclude  dilata- 
tion.      The     most    accurate     method     is     by    inflating    the 


IIEMORRI/AGE   FROM    THE   S'JVMACIL  433 

stomach  and  then  by  determining^  the  upi;ei'  and  lower 
borders  by  inspection,  palpation,  and  percussion.  Gastro- 
diaphany,  or  the  electric  illumination  of  the  stomach,  is 
the  least  accurate  of  the  methods  at  command.  The 
diagnosis  should  n(jt  be  considered  complete  unless  the 
presence  and  extent  of  an  associated  atony  and  the  secre- 
tory functions  of  the  stomach  be  investigated.  If  dilata- 
tion occur  as  a  complication,  it  is  of  importance  to  differen- 
tiate between  a  pyloric  spasm  and  the  other  causes  of 
pyloric  obstruction. 

Prog-nosis  is  unfavorable  for  permanent  recovery,  although 
much  can  be  done  by  treatment.  The  prognosis  is  better 
in  the  cases  without  atony. 

Treatment. — The  clothing  should  be  loose  and  sus- 
pended from  the  shoulders,  so  that  constriction  about  the 
waist  does  not  occur.  Anaemic  conditions  should  receive 
appropriate  medication  and  the  general  health  should  be 
improved  in  every  possible  way.  Should  the  abdominal 
wall  be  weak,  a  tight,  well-fitting  abdominal  belt  is  of  ser- 
vice. It  should  be  adjusted  before  rising  and  worn  through- 
out the  day.  The  diet  should  be  general.  When  atony 
complicates,  small,  frequent  meals  are  indicated  and  intra- 
gastric faradism  should  be  employed.  Gastric  neuroses 
should  receive  appropriate  treatment.  The  bowels  should 
be  controlled  by  diet  and  by  ensemata,  as  cathartics  are 
contraindicated.  Lavage  is  not  to  be  employed  unless 
dilatation  or  gastritis  affords  positive  indications  for  its 
use.  Surgical  treatment  is  not  to  be  advised  unless  dilata- 
tion occur,  in  which  case  gastro-enterostomy  may  be  in- 
dicated. Before  advising  such  an  operation,  however,  a 
functional  pyloric  spasm  should  be  excluded  as  a  cause, 
as  these  cases  usually  yield  to  internal  medication  w'ithout 
operation. 


HEMORRHAGE   PROM   THE    STOMACH. 
Synonyins. — Haematemesis ;  Gastrorrhagia. 
Etiology. — The  causes  of  hemorrhage  from  the  stomach 
are  exceedingly  various  ;  they  may  be  grouped  as  follows  : 

28 


434        MAXrAL    OF  THE   PRACTICE    OF  MEDIC  EVE. 

1.  Traiiinatisin. — (<?)  Mechanical  injuries,  as  blows  or 
falls ;  penctratin>^  wounds  or  the  rough  introduction  of  a 
stiff  stomach-tube.  (/')  Chemical  injuries  by  strong  acids  or 
alkalies  or  by  corrosives. 

2.  Local  Disease  of  the  Stomach. — {a)  Ulceration  from 
ulcer  or  cancer,  [h)  Disease  of  the  blood-vessels,  such  as 
miliary  aneurysm,  atheromatous  or  fatt\^  degeneration,  or 
varices  of  the  veins. 

3.  Congestion  of  the  Gastric  Mucous  Meinbrane. — (<?)  Ac- 
tive congestion.  This  condition  may  occur  with  acute 
gastritis.  Under  this  heading  may  be  included  vicarious 
menstruation  b\-  way  of  the  stomach,  iji)  Passive  conges- 
tion. This  condition  occurs  with  cirrhosis  of  the  liver, 
thrombosis  of  the  portal  vein,  or  pressure  on  the  vein  by  a 
tumor.  It  occurs  secondarily  with  chronic  diseases  of  the 
heart  or  of  the  lungs  attended  by  general  venous  conges- 
tions. Congestion  of  the  stomach  often  arises  from  splenic 
enlargement,  being  explained  by  the  intimate  relations 
between  the  vasa  brevia  and  the  splenic  circulation.  Con- 
gestion occasional!}-  occurs  during  the  expulsive  efforts  of 
parturition. 

4.  Disorganized  Blood-conditioiis. — {a)  Hrematemesis  may 
occur  with  any  of  the  severe  infectious  diseases,  especially 
yellow-fever,  small-pox,  measles,  scarlet  fever,  relapsing 
fever,  malaria,  and  typhus  fever.  In  these  cases  it  is  usually 
associated  with  other  hemorrhages  from  mucous  membranes 
and  under  the  skin,  {b)  Toxic  conditions,  such  as  cholsemia 
and  poisoning  from  phosphorus,  (r)  Hemorrhagic  diseases. 
Among  these  diseases  are  to  be  mentioned  scorbutus  and 
purpura  hjemorrhagica.  Under  this  heading  may  be  in- 
serted haemophilia,  {d)  Profound  ana^^mia,  whether  idio- 
pathic, malarial,  leukaimic  or  pseudo-leukaemic,  or  due  to 
Addison's  disease. 

5.  Nervous  Causes. — There  are  cases  of  haematemesis  not 
infrequently  occurring  in  hysterical  subjects  without  assign- 
able cause.  The  disease  is  not  uncommon  with  progressive 
paralysis  of  the  insane  and  with  epilepsy. 

6.  Idiopathic  Hemorrhage. — This  condition  was  described 


IIEMORRI/AGE   FROM   THE   STOMACH.  435 

by  Flint  as  hemorrhage  occurring,  as  it  often  does  from  the 
nose,  without  assignable  cause,  and  not  being  due  to  any 
morbid  condition. 

7.  Mcicsna  Ncoiiatonivi. — This  is  a  severe  and  usually  fatal 
hemorrhage  occurring  in  infants  within  the  first  two  weeks 
of  life.  It  may  occur  in  healthy  children  or  in  those  with  a 
family  history  of  haemophilia,  or  it  may  occur  in  prema- 
turely born  children  from  too  early  an  interruption  of  the 
fetal  circulation.     In  some  cases  it  depends  on  gastric  ulcer. 

8.  The  blood  may  not  come  primarily  from  the  stomach, 
but  may  flow  into  it.  In  haemoptysis,  epistaxis,  or  bleeding 
from  the  throat  blood  may  be  swallowed,  to  be  vomited 
later.  Blood  may  trickle  down  from  the  oesophagus  from 
rupture  of  varicose  veins  in  its  wall,  from  ulceration,  or 
from  rupture  into  it  of  a  neighboring  aneurysm.  The  blood 
may  enter  the  stomach  from  rupture  into  it  of  an  aneurysm 
of  the  abdominal  aorta  or  one  of  its  branches,  or  ulceration 
may  perforate  the  heart  or  the  lungs,  allowing  of  haemor- 
rhage in  this  way.  Nursing  babies  may  swallow  blood 
from  the  mother's  breast,  as  from  cracked  and  bleeding  nip- 
ples. Hysterical  patients  often  swallow  blood  from  slaugh- 
ter-houses, and  vomit  it  to  obtain  the  sympathy  of  friends. 

The  symptoms  consist  of  hemorrhage  and  anaemia.  In 
rare  cases  the  patient  may  die  before  any  blood  has  been 
vomited  or  passed  with  the  stools.  In  all  cases  of  profuse 
hemorrhage  some  blood,  and  in  rarer  cases  all  the  blood, 
may  be  passed  by  the  bowels,  giving  the  stools  a  black, 
tarry  appearance.  Water  added  to  such  stools  will  develop 
a  more  characteristic  blood  color.  The  amount  of  blood 
lost  may  amount  to  three  or  four  pounds  in  the  course  of  a 
single  day.  Anaemic  symptoms  are  marked  in  proportion 
to  the  amount  of  blood  lost. 

Diagnosis. — Careful  inspection  usually  leaves  no  doubt 
that  it  is  blood  that  is  vomited.  Should  doubt  exist,  re- 
course may  be  had  to  the  microscope,  the  spectroscope,  and 
the  test  for  h^emin-crystals.  The  diagnosis  from  hsemop- 
tysis  is  to  be  based  upon  the  points  contained  in  the  follow- 
ing table,  compiled  by  Welch  : 


436 


M.i.VLAL    OF  THE    PRACTICE    OF  MFDICIXE. 


Hicmopty^is. 

1.  Usually  preceded  by  symptoms 
of- pulmonary  or  cardiac  disease.  Bron- 
chial hemorrhage  witlioui  evidence  of 
preceding  disease  is  not  rare. 

2.  The  attack  begins  wiih  a  tickling 
sensation  in  the  throat  or  behind  the 
sternum.  The  blood  is  raised  by  cough- 
ing. Vomiting,  if  it  occurs  at  all,  fol- 
lows the  act  of  coughing. 

3.  The  blood  is  bright  red,  fluid  or 
but  slightly  coagulated,  alkaline,  frothy, 
and  frequently  mi.xed  wiih  muco-pus. 
If  the  blood  has  remained  some  time 
in  the  bronchi  or  in  a  cavity,  it  be- 
comes dark  and  coagulated. 


4.  The  attack  is  usually  accompa- 
nied and  followed  by  localized  moist 
rales  in  the  chest,  and  there  may  be 
other  physical  signs  of  pulmonary  or 
cardiac  disease.  Bloody  sputum  con- 
tinues for  some  time,  often  for  days, 
after  the  profuse  hemorrhage  ceases. 


Hamatcmesis. 

1.  Usually  preceded  by  .symptoms 
of  gastric  or  hepatic  disease,  less  fre- 
quently by  symptoms  of  other  diseases. 

2.  The  attack  begins  with  a  feeling 
of  fulness  in  the  stomach,  followed  by 
nausea.  The  blood  is  expelled  by 
vomiting,  to  which  cough,  if  it  occurs, 
is  secondary. 

3.  The  blood  is  dark,  often  black 
and  grumous,  sometimes  acid,  and  usu- 
ally mingled  with  the  food  and  other 
contents  of  the  stomach.  If  the  blood 
is  vomited  at  once  after  its  effusion,  it 
is  bright  red  and  alkaline;  or  it  may 
be  alkaline  if  it  is  efiused  into  an  empty 
stomach. 

4.  After  the  attack  the  physical  ex- 
amination of  the  lungs  is  usually  nega- 
tive, but  there  are  generally  symptoms 
and  signs  of  g.astric  or  hepatic  disease. 
Black  stools  follow  profuse  haimatem- 
esis. 


The  treatment  of  ha^matemesis  is  considered  under  Gas- 
tric Ulcer,  page  422. 

GASTRIC  NEUROSES. 

The  symptoms  of  gastric  neuroses  may  resemble  very 
closely  those  of  organic  affections,  but  possess,  however, 
certain  characteristics  in  common  which  suggest  a  neurotic 
basis. 

1.  There  is  more  or  less  involvement  of  the  general 
nervous  .system — the  symptoms  depend  largely  upon  the 
nervous  and  physical  condition,  and  are,  therefore,  more 
intermittent  than  are  the  symptoms  of  organic  disease.  It 
is  often,  however,  difficult  to  distinguish  between  a  chronic 
disorder  and  a  secondary  neurasthenia  and  a  primary 
neurosis.  In  many  cases  gastric  analysis  alone  will  deter- 
mine the  diagnosis. 

2.  The  symptoms  are  not  steadily  dependent  upon  the 
quantity  or  quality  of  food.     Almost  everything,  no  matter 


GASTK/C  NEUROSES.  437 

how  simple  in  character,  tends,  at  some  time  or  another,  to 
produce  distress.  The  natural  result  is  that  the  great 
majority  of  patients  over-diet,  the  nutrition  suffers,  and  the 
neurasthenia  is  rendered  more  extreme. 

3.  The  symptoms  are  of  changeable  character.  This  is 
especially  seen  in  the  secretory  function.  Total  anacidity 
may  be  varied  by  normal  or  excessive  hyperacidity.  Similar 
changes  in  the  motor  functions  often  occur — atony  rapidly 
alternating  with  hypermotility. 

Gastric  neuroses  may  evince  themselves  in  any  of  the 
gastric  functions.     We  distinguish,  therefore — 

1.  Sensory  neuroses. 

2.  Secretory  neuroses. 

3.  Motor  neuroses. 

Sensory  Neuroses. 

1.  Bulimia  is  an  uncontrollable  impulsive  hunger,  and  is 
due  to  excessive  irritation  of  the  hunger-sense.  In  many 
cases  it  is  due  to  an  excessive  motility,  so  that  the  stomach 
empties  itself  too  rapidly. 

2.  Nervous  anorexia  is  due  to  anaesthesia  of  the  hunger- 
sense.  It  is  characterized  by  an  absolute  repugnance  for 
food,  and  is  common  among  hysterical  girls  and  the  insane. 
The  patient  is  often  reduced  to  an  extreme  degree  of  inan- 
ition, and  forced  feeding  through  a  stomach-tube  may 
become  a   matter  of  absolute   necessity. 

3.  Gastralgia ;  Gastrodynia. — Neuralgic  pain  in  the 
stomach  may  occur  as  a  symptom  of  organic  disease,  as 
ulcer  or  cancer,  or  in  the  form  of  the  "  gastric  crises  "  of 
locomotor  ataxia.  Aside  from  these  cases,  gastralgia  may 
occur  as  a  functional  neurosis,  independent  of  organic  dis- 
ease, and  to  this  form  the  term  "gastralgia"  should  properly 
be  confined. 

Etiology.  —  Most  patients  are  neurasthenic,  hysterical 
women,  usually  those  of  the  change  of  life,  but  young 
women  and  men  ma}^  also  be  affected.  The  attack  seems 
to  be  favored  by  a  gouty  tendency,  malarial  poisoning,  hys- 
teria, and  hyperacidity  or  hypersecretion.  Gastralgia  is  one 
of  the   regular  symptoms   of  chronic    poisoning    by   lead. 


43 S        MAXCAL    OF  THE   PRACTICE    OF  MEDICIXE. 

Tlie  attacks  may  be  induced  by  excessive  chcwini^  cf  to- 
bacco or  by  o\er-indulL;ence  in  tea. 

Syjiiptoiiis. —  The  disease  appears  in  attacks  of  t^astric 
pain,  of  a  binniny;,  tearing,  or  borini;  character,  usually  re- 
ferred to  the  epigastrium,  and  occasionall}'  radiating  to  the 
back  and  around  the  waist.  Light  pressure  is  grateful,  but 
tenderness  is  usually  elicited  by  firm  pressure.  Vomiting 
is  rare.  Relief  is  frequently  afforded  b}'  eating.  During 
the  attack  the  abdomen  is  usualK'  retractetl,  and  the  patient 
assumes  a  generally  flexed  position.  The  attacks,  which 
last  from  a  few  minutes  to  several  hours,  may  be  repeated 
at  irregular  intervals,  or  they  may  occur  with  such  period- 
icity as  to  suggest  a  malarial  influence.  They  may  recur 
at  night,  and  they  are  usually  independent  of  eating,  al- 
though in  some  cases  pain  may  arise  from  dietetic  causes. 
The  symptoms  of  gastralgia  are  usually  associated  with 
those  of  a  neurasthenic  or  h}'stcrical  nature,  giving  a  de- 
cidedly neurotic  stamp  to  the  majority  of  cases. 

There  are  many  cases  of  patients  who  have  over-dieted 
and  in  whom  every  article  of  diet,  however  simple,  gives 
pain.  These  cases  are  regularly  improved  by  full  diet,  rest 
in  bed,  hot  applications  over  the  abdomen,  and  small  doses 
of  bromide.  To  these  cases  the  term  gastric  hyperzesthesia 
is  often  given. 

The  diagnosis  is  to  be  made  b\'  the  exclusion  of  organic 
lesions  and  by  the  general  view  of  the  case,  showing  admix- 
ture of  neuralgic  and  neurasthenic  symptoms.  The  diag- 
nosis, especially  from  ulcer,  is  often  made  with  great  diffi- 
cu]t^^  In  all  obscure  cases  of  gastralgia  the  possibility  of 
cholelithiasis  should  be  considered. 

The  prognosis  depends  upon  the  curabilit}-  of  the  under- 
lying cause. 

Treatment. — Fdr  the  attack  itself,  hot  applications  or  a 
mustard  paste  may  be  applied  to  the  epigastrium.  Carmin- 
atives are  often  of  service — Hoffmann's  anodyne,  spirits  of 
chloroform,  or  valerian.  Morphine  is  not  to  be  used,  on 
account  of  the  possibility  of  a  habit  being  formed ;  while 
cocaine  is  not  recommended,  because  of  its  extreme  depres- 
sant effect.     Relief  is  frequently  afforded  during  an  attack 


GASTRIC  NEUROSES.  439 

by  copious  draughts  of  hot  water.  J>rilliant  results  often 
follow  the  use  of  small  doses  of  bromide,  chloral,  and 
chlorform-water,  as   in   the   following   prescrij)tion : 

I^   Sodii  bromid.,  gr.  vj  ; 

Chloral  hydrat.,  gr.  iij  ; 

Aq.  chloroform.,  3J ; 

Spiritus  anis.,  gr.  \. — M. 
Sig. — Such  a  dose  four  times  a  day. 

To  prevent  recurrences  the  underlying  cause  should  be 
detected  and  removed.  Neurasthenic  conditions  require 
appropriate  treatment.  Arsenic  in  free  doses,  but  not  to  the 
point  of  tolerance,  frequently  acts  as  a  specific.  The  com- 
bination of  valerianate  of  zinc  (gr.  iij)  with  small  doses  (gr. 
■|-)  of  nitrate  of  silver  is  often  useful.  Hyperacidity  and 
hypersecretion,  if  present,  require  their  special  treatment. 

Secretory  Neuroses. 

1.  Nervous  subacidity  occurs  as  a  temporary  condition 
in  depressed  mental  conditions.  It  commonly  occurs  during 
the  first  few  days  of  menstruation  in  healthy  subjects.  The 
subacidity  of  the  chronic  gastritis  can  be  usually  excluded 
(i)  when  ferments  and  zymogens  are  present  in  normal 
proportions  and  (2)  when  subacidity  varies  with  normal  or 
excessive  secretion. 

2.  Hyperacidity  exists  where  HCl  is  present  in  over  ^-^ 
per  cent,  after  a  test-breakfast,  and  is  one  of  the  most  com- 
mon forms  of  indigestion.  Before,  however,  a  diagnosis  of 
neurotic  hyperacidity  is  made,  gastritis  with  over-production 
of  HCl,  ulcer,  atony,  and  pyloric  obstruction  must  be  ex- 
cluded. There  is  pain  of  a  gnawing,  burning  character, 
which  is  referred  to  the  epigastrium  or  the  heart,  or  it 
may  be  substernal.  It  is  often  spoken  of  as  "  heart-burn." 
There  are  eructations  of  acid  fluid  setting  the  teeth  on  edge. 
Digestion  for  starches  is  usually  delayed.  The  symptoms 
usually  occur  one  to  two  hours  after  eating  or  may  be 
longer  delayed.  Instant  relief  is  usually  afforded  by  the 
administration  of  alkalies  or  the  taking  of  food.     There  are 


440      .u.ixr.i/.  OF  THE  pkactick  of  medicixe. 

certain  cases  wliich  |;i\c  tlicsc  symptoms  in  which  L^astric 
analwsis  shows  a  ni^)rmal  iJcrccntai^e  of  IICI,  ami  arc  to  be 
cx[)hiinc(.l  by  there  bein^  a  pecuhar  hxpcr.csthesia  or  sen- 
siti\encss  of  the  stomach  to  acitl. 

3.  Periodic  Hypersecretion. — Syiioitynts. —  Gastrosuccor- 
rhcea  or  Rossbach's  ^.istroxynsis. — There  occur,  from  time 
to  time,  attacks  of  burning  gastric  pain,  with  vomiting  of 
acid  fluid  containing  IICI.  The  attack  lasts  from  a  few 
hours  to  several  da}s.  The  condition  may  occur  as  a 
primary  neurosis,  occurring  especially  among  the  educated 
classes,  or  it  ma)'  be  secondary  to  disease  of  the  central 
nervous  system,  as  locomotor  ata.xia,  m)'clitis,  or  progres- 
sive paresis.  It  is  not  uncommon  as  a  complication  of 
gastric  ulcer. 

4.  Continual  Hypersecretion  {Rcichviaiuis  7)iscasi-). — 
This  condition  is  characterized  by  the  constant  presence  of 
gastric  juice  in  the  fasting  stomach.  To  be  of  pathological 
significance,  at  least  75  c.c.  should  be  obtained  on  a  number 
of  occasions,  as  smaller  amounts  maybe  present  in  a  variety 
of  other  conditions,  or  as  large  a  quantity  may  appear  as  a 
temporary  phenomenon  in  otherwise  healthy  stomachs. 

Excluding  these  minor  or  transitory  cases,  Reichmann's 
disease  is  a  somewhat  rare  condition.  It  does  not  appear 
to  be  a  primary  neurosis. 

There  is  no  distinct  pathological  cause.  The  majority  of 
cases  complicate  gastric  aton\',  ulcer,  or  the  milder  degrees 
of  p)'loric  obstruction,  whether  of  organic  or  spasmodic 
origin.  It  may  also  occur  with  the  hyperacid  form  of 
chronic  gastritis. 

The  syinptoiiis  are  those  of  hyperacidity.  Burning  pain 
is  often  complained  of  in  the  fasting  condition,  so  that  the 
patient  is  obliged  to  take  soda  during  the  night  or  before 
breakfast.  The  great  majority  of  cases  present  a  variety  of 
neurasthenic  symptoms. 

Trcatuieiit  is  often  very  unsatisfactory.  The  fluid  may  be 
withdrawn  every  morning  before  breakfast,  through  a  tube. 
Good  results  have  been  obtained  by  the  systematic  use  of 
alkalies  and  by  the  emplo\nient  of  atropine.  A  tablespoon- 
ful  of  olive  oil  before  meals  has  also  been  of  service.    Carls- 


GA:vrh-ic  NEUROSES.  441 

bad  or  Vichy  waters  may  be  used — Llie  former  before  meals, 
the  latter  between  meals.  Atonic  conditions  of  the  stomach- 
wall  should  be  controlled  by  frequent  feedings  and  by 
intragastric  faradism. 

Motor  Neuroses. 

1.  Nervous  Vomiting-. — Nervous  vomiting  does  not  arise 
from  organic  disease,  but  is  a  pure  motor  neurosis  depending 
upon  cerebral  or  reflex  irritation. 

Etiology. — Nervous  vomiting  may  accompany  lesions  of 
the  brain,  the  cord,  or  the  meninges,  hysteria,  neurasthenia, 
or  migraine.  It  may  be  due  to  reflex  irritation  from  lesions 
of  the  abdominal  or  pelvic  organs,  and  it  occurs  with  sea- 
sickness and  pregnancy.  In  neurasthenic  males  nervous 
vomiting  may  be  due  to  irritation  of  the  genito-urinary 
organs.  The  gastric  crises  of  locomotor  ataxia  are  described 
elsewhere.  The  "periodical  vomiting  "  of  Leyden  is  asso- 
ciated with  gastric  pain  ;  it  occurs  in  anaemic  and  nervous 
patients. 

The  synipioins  of  nervous  vomiting  differ  from  those  of 
ordinary  vomiting  in  that  nausea  and  retching  are  seldom 
observed.  It  is  rather  a  regurgitation  than  a  vomiting 
Food  is  usually  ejected  after  meals,  but  the  vomiting,  which 
may  occur  at  irregular  intervals,  is  so  little  dependent  upon 
dietetic  errors  that  the  name  "  causeless  vomiting  "  is  often 
applied  to  these  cases.  In  hysterical  cases,  although  all 
food  may  apparently  be  vomited,  the  general  nutrition  may 
remain  good. 

Treatment  is  to  be  directed  to  the  underlying  cause. 
Change  of  climate  is  often  of  great  service,  especially  in 
cases  of  the  primary  periodic  vomiting  of  Leyden. 

2.  Peristaltic  Unrest. — Peristalsis  of  the  stomach  is  in- 
creased, with  the  production  of  loud  splashing  sounds  often 
heard  at  a  considerable  distance.  This  condition  is  not  un- 
common in  neurasthenic  subjects;  it  is  usually  increased  by 
emotions. 

3.  Rumination ;  Merycismus. — H}'sterical  and  feeble- 
minded patients  ma}'  regurgitate  the  food  and  chew  the  cud 
like  ruminating  animals.     The  habit  is  frequenth-  difficult  to 


442        MJXL'AL    OF   THE   PA'ACTICE    OF  MED/CLVE. 

cure,  but  it  seems  to  exert  no  evil  elTect  upon  the  {general 
health. 

4.  Nervous  eructation  consists  in  the  eructation  of  large 
quantities  of  gas,  indcpentlent  of  food.  The  eructations  are 
accompanied  with  spasmodic  contraction  of  the  participating 
muscles,  arc  explosive  in  character,  and  are  not  under 
mental  control.  The  gas  raised  is  atmospheric  air  that  has 
been  swallowed. 

5.  Pyloric  spasm  may  occur  with  hyperaisthesia  of  the 
stomach,  with  hyperacidity,  and  with  dilatation  of  the 
stomach  with  gases  as  a  reflex  neurosis.  It  commonly 
complicates  ulcer  of  the  pylorus.  The  attack  gives  rise  to 
considerable  cramp-like  pain  referred  to  the  epigastrium, 
and  there  is  stagnation  of  food.  In  ordinary  cases  the 
attack  subsides.  In  other  cases  it  continues,  and  may  give 
rise  to  a  considerable  degree  of  dilatation. 


3,  DISEASES  OF  THE  INTESTINES. 

MORNING    DIARRHCEA. 

The  etiology  and  pathology  of  morning  diarrhoea  are 
unknown.  It  is  probable  that  the  disease  is  functional  and 
not  mflammatory.  Some  cases  seem  due  to  a  sagging  of 
the  transverse  colon  {coloptosis). 

The  symptoms  consist  of  diarrhoea,  usually  limited  to 
the  early  morning  hours.  There  may  be  but  one  passage, 
or  the  diarrhoea  may  continue  throughout  the  forenoon. 
The  passages  are  usually  painless  and  are  accompanied  by 
the  passage  of  flatus.  The  diarrhoea  may  be  varied  by 
periods  during  which  the  bowels  are  normal  or  consti- 
pated. Mental  worry  is  usually  associated  with  the  dis- 
ease, and  exhaustion  may  occur  should  the  diarrhoea  be 
excessive.  In  protracted  cases  the  diarrhoea  begins  at  an 
earlier  hour  of  the  morning,  so  that  patients  may  be  awak- 
ened at  four  or  five  o'clock  in  the  morning  with  pain  and 


ACUTE    CAJARRIIAL    EN'rKK/TIS.  443 

an  urgent  desire  for  stool.  In  long-continued  cases  there 
may  be  developed  a  sense  of  impending  movement  of  the 
bowels  whenever  any  food  is  taken  into  the  stomach. 

Treatment. — A  change  of  climate  is  frequently  followed 
by  a  most  brilliant  result,  which  in  the  majority  of  cases  is 
permanent.  The  general  health  should  be  built  up  ;  various 
modifications  of  diet  should  be  tried,  such  as  diets  from 
which  the  starches  and  sugars  are  excluded,  or  a  diet  of 
meat  alone.  The  treatment  by  drugs  is  not  satisfactory, 
but  salol,  naphthaline,  and  the  subgallate  of  bismuth  may 
be  used.  Delafield  finds  his  best  results  to  have  followed 
castor  oil  in  doses  of  from  5  to  10  drops. 

ACUTE  CATARRHAL  ENTERITIS. 

Synonyms. — Acute  ileo-colitis  ;  Acute  entero-colitis ; 
Acute  intestinal  catarrh  ;  Acute  diarrhoea. 

While  certain  portions  of  the  small  intestine  may  be  in- 
flamed more  than  others,  it  is  not  usually  possible  during 
life  to  say  which  portion  is  especially  involved.  In  the 
great  majority  of  cases  the  small  intestine  throughout  its 
length  is  affected,  together  with  the  upper  portion  of  the 
large  intestine,  and  to  this  condition  the  names  of  "  enter- 
itis "  and  "  entero-colitis  "  are  applied. 

Duodenitis  causing  catarrhal  jaundice  will  be  considered 
under  the  latter  heading. 

Etiology. — The  causes  may  be  primary  or  secondary. 

Primary  Causes. —  i.  Error  in  food,  either  in  quantity  or 
in  quality.  The  commonest  cause  is  the  ingestion  of  unripe 
fruit  or  of  food  or  milk  in  which  decomposition-changes 
have  taken  place  before  its  ingestion.  Individual  peculiari- 
ties play  a  considerable  part  in  the  causation  of  the  disease, 
for  what  is  food  for  one  may  be  poison  for  another. 

2.  Impurities  in  drinking-water  often  cause  epidemics  of 
enteritis.  Strangers  are  more  susceptible  to  such  impurities 
than  are  those  who  are  accustomed  to  the  water. 

3.  Toxic  causes,  such  as  irritant  food  or  drugs,  either 
alkaline,  acid,  or  corrosive. 

4.  A  sudden  fall  in  temperature  or  the  chilling  of  the 
surface  after  excessive  perspiration  may  induce  an  attack. 


444        -V.LVr.lZ.    OF   THE   PRACTICE    OF  MEDICIXE. 

5.  Changes  in  the  intestinal  secretions  may  theoretically 
give  rise  to  conditions  leading  to  catarrh,  but  of  these 
changes  we  know  practically  but   little. 

Secondary  Causes. —  i.  Enteritis  is  often  secondary  to  any 
gastric  cause  allowing  fermenting  or  undigested  food  to  pass 
into  the  intestine. 

2.  Peritonitis  or  any  organic  disease  of  the  intestine,  such 
as  ulcer,  hernia,  or  cancer. 

3.  Enteritis  is  favored  by  any  chronic  congestion  of  the 
intestinal  blood-vessels  from  chronic  heart  or  lung  disease, 
or  by  any  cause  producing  obstruction  in  the  portal  circu- 
lation. 

4.  Enteritis  often  occurs  in  the  course  of  acute  infectious 
disease ;  it  may  attend  chronic  cachectic  conditions,  such  as 
those  occurring  with  cancer,  tuberculosis,  Bright's  disease, 
or  anjumia. 

Pathology. — The  mucous  membrane  is  red,  swollen,  con- 
gested, and  covered  with  mucus.  These  pathological  ap- 
pearances often  disappear  after  death,  leaving  the  mucosa 
pale  and  sodden.  The  solitary  and  agminated  glands  are 
swollen  and  prominent,  especially  in  children.  Follicular 
and  catarrhal  ulceration  may  occur. 

Symptoms. — There  is  pain  of  a  colicky  character,  which 
ma\-  be  diffused  or  ma}-  be  localized  at  the  umbilicus.  It  is 
usually  worse  before  an  evacuation,  and  is  generally  relieved 
by  firm  pressure.  A  tendenc}-  to  straining  indicates  that  the 
lower  portion  of  the  colon  is  involved.  Tjmipanites  and 
gurgling  noises  or  borborygmi  usually  accompan)'  the  attack, 
being  due  to  the  presence  of  fluid  and  gas  within  the  intes- 
tine and  to  increased  peri.stalsis.  If  the  inflammation  be  con- 
fined to  the  small  intestine,  there  need  be  no  diarrhoea.  If  the 
colon  be  involved,  there  is  a  loose  fecal  diarrhoea,  the  thin, 
gruel-like  stools  often  containing  portions  of  undigested  food 
(lienteric  diarrhoea)  and  flakes  of  brownish  mucus.  The  color 
of  the  stools  varies  from  dark  brown  to  yellow,  or  even  to 
gray,  according  to  the  amount  of  bile  with  which  they  are 
mixed.  The  number  of  evacuations  varies  from  three  or  four 
up  to  twenty  in  the  course  of  the  day.  There  is  usually  loss 
of  appetite,  with  occasionally  nausea  or  vomiting.     Fever 


CHRONIC   C.rrARRHAL    KNTKRITIS.  445 

may  be  absent,  or  there  may  be  a  rise  of  temperature  of  a 
few  degrees. 

The  prognosis  is  perfectly  good,  the  attack  lasting  from 
five  days  to  a  week  and  terminating  in  recovery.  Relapses 
are  frequent  from  repetitions  of  the  original  exciting  cause. 

Treatment. — In  mild  cases  rest  and  a  restricted  diet  suf- 
fice. The  dietetic  rules  to  be  observed  in  chronic  gastritis 
are  applicable  to  these  cases.  In  more  severe  cases  a  milk 
diet  during  the  acute  attack  may  be  indicated.  The  patient 
should  be  kept  warm,  and  a  flannel  band  over  the  abdomen 
is  of  service,  particularly  in  children.  A  cathartic  is  usually 
indicated  at  the  onset,  despite  the  existence  of  diarrhoea. 
The  best  drug  for  this  purpose  is  castor  oil  or  calomel.  It 
is  not  wise  to  check  diarrhoea  for  forty-eight  hours.  After 
this  time  astringents  may  be  given,  combined  with  opium 
in  small  doses.  Bismuth  subnitrate  in  gr.  xx— xxx  doses 
every  two  hours  is  usually  efficient.  Pain  may  be  controlled 
by  hot  applications  to  the  abdomen,  by  small  doses  of  opium, 
or  by  spirits  of  chloroform  in  .5ss  doses. 

CHRONIC  CATARRHAL  ENTERITIS. 

Etiology  and  Synonyms. — Chronic  catarrhal  enteritis 
rarely  occurs  as  a  primary  disease.  It  may  follow  repeated 
acute  attacks,  or  may  be  due  to  the  continuance  of  improper 
food  and  hygiene.  In  these  cases,  however,  there  is  usually 
a  chronic  gastritis  or  atony  to  which  the  enteric  catarrh  is 
secondary.  It  follows  chronic  congestion  of  the  portal 
circulation  and  chronic  lung  and  heart  diseases.  It  may 
follow  a  great  variety  of  gastric  disorders,  and  it  occurs 
with  chronic  lesion  of  the  intestine,  such  as  cancer  or  tuber- 
cular inflammation.  Cachectic  and  debilitated  conditions 
predispose  to  the  disease,  and  it  seems  to  be  more  common 
in  those  with  a  gouty  tendency.  Synonynns :  Chronic  intes- 
tinal catarrh  ;  Chronic  diarrhoea  ;  Chronic  catarrhal  entero- 
colitis. 

Pathology. — The  lesion  is  a  chronic  catarrhal  inflamma- 
tion of  the  small,  and  usually  of  the  large,  intestine.  The 
mucous  membrane  is  generally  congested  and  covered  with 
mucus,  and  the  wall  of  the  intestine  is  thickened  by  hyper- 


446        M.lXr.lL    OF   THE    P/^.tCT/CE    OF  MEDICIXE. 

troph}'  of  all  its  la\'or.s.  In  other  cases  the  wall  of  the  in- 
testine is  thinned,  the  glandular  elements  undergo  atrophy, 
and  the  mucous  membrane  is  grayish  or  lead-colored.  The 
lymph-follicles  are  swollen  and  pigmented.  Pigmentation 
of  the  villi  also  occurs.  Catarrhal  or  follicular  ulceration 
is  seen  in  severe  cases,  the  latter  form  being  especially  well 
marked  in  the  lymph-follicles  of  the  descending  colon  and 
the  sigmoid  flexure.  The  close  approximation  ofthe.se  con- 
ical ulcers  often  gives  to  the  colon  a  sieve-like  or  honey- 
combed appearance.  These  ulcers  ma\-  perforate  or  be  the 
seat  of  hemorrhage. 

The  symptoms  of  chronic  catarrhal  enteritis  resemble 
those  of  acute  entero-colitis,  but  are  more  protracted.  As 
the  large  intestine  is  almost  regularly  involved,  diarrhcea  is 
a  prominent  symptom  in  most  cases.  In  other  patients 
diarrhoea  alternates  with  periods  of  constipation.  The  stools 
usually  are  thin  and  fecal,  containing  undigested  food  mixed 
with  mucus.  If  mucus  be  evenly  admixed  with  the  stool, 
its  source  is  probably  the  small  intestine  ;  if  it  coat  the  stool, 
it  comes  from  the  large  intestine.  The  patient  frequently 
passes  lumps  or  strings  of  glairy  mucus,  which  may  com- 
prise the  entire  stool.  Blood  or  pus  may  be  present  in  the 
dejecta,  the  presence  of  the  latter  being  a  sure  indication  of 
the  existence  of  ulceration.  The  number  of  stools  varies 
from  one  to  eight  in  the  course  of  the  day.  In  some  cases 
the  diarrhoea  occurs  in  the  early  morning  hours  ;  in  other 
cases  it  is  induced  by  eating. 

Pain  to  some  degree  is  usually  present.  It  ma}'  be  dif- 
fused, or  localized  at  the  umbilicus  and  of  a  colicky  cha- 
racter. It  is  most  common  in  from  one  to  three  hours  after 
eating.  In  other  cases  there  is  only  a  sense  of  oppression 
and  fulness.  Borborygmi  and  flatulence  accompany  the 
disease,  and  there  may  be  symptoms  of  an  associated  gas- 
tritis or  of  functional  disturbance  of  the  liver.  In  aggra- 
vated cases  the  general  health  fails,  the  patient  becoming 
thin  and  weak,  and  the  emaciation  and  prostration  may  be 
extreme.  Hypochondriasis  or  melancholia  may  occur.  In- 
dicanuria  is  very  frequently  present. 

The  prognosis  for  perfect  recovery  is  usually  bad,  although 


PHLEGMONOUS  ENTER  IT  IS.  ^^-J 

much  may  be  done  to  relieve  the  patient.  There  arc  usually 
periods  of  temporary  improvement,  even  if  the  case  be  not 
treated.  The  disease  may  be  fatal  in  debilitated  and  a,e,^ed 
patients  and  in  children.  The  rare  accident  of  perforation 
should  not  be  forgotten. 

Treatment  depends  upon  the  primary  disorder.  In  every 
case  careful  examination  for  gastric  disorders  should  be 
made,  and  these  should  be  appropriately  treated.  The  diet 
should  be  regulated  to  suit  the  particular  needs  of  each  case, 
and  determined  by  the  results  of  gastric  analysis.  Cathar- 
tics are  absolutely  contraindicated,  but  if  constipation  exists, 
the  bowels  should  be  regulated  by  diet,  massage,  or  faradi- 
zation. If  diarrhoea  is  present,  astringents  with  intestinal  dis- 
infectants are  indicated.  Among  these  may  be  mentioned 
subnitrate  of  bismuth,  3ss-j ;  subgallate  of  bismuth,  gr.  x-xx; 
naphthaline,  gr.  x-xv ;  salicylate  of  bismuth,  gr.  x-xx ;  or 
salol,  gr.  v-x, — these  doses  being  repeated  three  or  four 
times  in  the  day.  Opium  should  not  be  given  as  a  routine 
treatment.  If  the  diarrhoea  depend  upon  ulceration  of  the 
colon,  large  colon  injections  should  be  used.  The  hips 
being  elevated,  the  injection  should  be  allowed  to  flow  in 
gradually  from  a  fountain  bag ;  in  this  way  from  two  to 
four  pints  of  injection  are  to  be  introduced,  and  it  may 
be  retained  for  some  time.  Simple  water  containing  3)  of 
soda  or  borax  or  salt  to  the  pint  may  be  used ;  the  addi- 
tion of  an  astringent  is  seldom,  if  ever,  necessary.  In  all 
cases  care  should  be  taken  to  build  up  the  general  health 
and  to  avoid  exposure  to  cold.  A  flannel  abdominal  band- 
age should  be  worn  constantly.  In  some  cases  the  best 
results  are  obtained  by  sending  the  patient  to  spend  the 
winters  in  a  warm,  dry  climate. 

PHLEGMONOUS   ENTERITIS. 

This  affection  is  exceedingly  rare  as  a  primary  disease, 
but  it  may  occur  in  connection  with  ulceration  of  the  intes- 
tine, strangulated  hernia,  and  intussusception.  The  puru- 
lent infiltration  may  be  localized  or  diffused. 

Symptoms. — The  primary  cases  run  a  peracute  course, 
with  pain,  tympanites,  constipation,  and  fever,  and  terminate 


44^        .V.-LVC.IA    OF   THE   PRACTICE    OF  MEDICIXE. 

by  septic  peritonitis.     These  cases  appear  to  be  clue  to  in- 
fection by  the  bacterium  coh   commune.     The  symptoms 
of  the  secondary  cases  may  be  obscured  by  those  of  the 
primary  disease,  so  that  the  diagnosis  is  seldom  made. 
Prognosis. — The  disease  is  rapidly  fatal. 

PSEUDO-MEMBRANOUS    ENTERITIS. 

Btiolog-y  and  Synonyms. — Pseudo-membranous  enteritis 
occurs  {ci)  as  a  secondary  process  in  acute  infectious  dis- 
eases, especially  typhoid  fever,  scarlet  fever,  and  cholera; 
(/^)  as  a  complication  of  dysentery  or  of  intestinal  obstruc- 
tion ;  {€)  in  conditions  of  advanced  cachexia;  (^/)  as  the 
result  of  poisoning  by  mercury,  lead,  and  arsenic,  and  in 
urajmic  conditions.  Symviyms :  Diphtheritic  or  Croupous 
enteritis. 

Pathology. — The  pseudo-membranous  inflammation  is 
usually  more  marked  in  the  colon,  but,  especially  in  the 
mercurial  and  uraemic  forms,  the  small  intestine  may  also 
be  involved.  Necrosis,  ulcerations,  perforation,  or  hemor- 
rhage may  result,  or  cicatricial  obstruction  may  ultimately 
develop. 

The  symptoms  are  latent  in  many  cases  secondary  to 
acute  infectious  diseases  and  to  cachectic  states.  In  other 
cases,  especially  in  the  mercurial  form,  the  symptoms  of  a 
violent  entero-colitis  are  developed.  Stools  consisting  of  a 
thin,  purulent  liquid  containing  blood  and  shreds  of  the 
pseudo-membrane  are  fairly  characteristic  of  this  affection. 
Hemorrhage  and  perforative  peritonitis  are  common  com- 
plications. 

This  disease  should  not  be  confounded  with  membranous 
or  mucous  colitis — an  entirely  distinct  disease. 

The  treatment  is  that  of  a  severe  acute  entero-colitis. 
Opium  should  be  given  to  limit  peristalsis  and  to  diminish 
the  danger  of  perforation  or  hemorrhage. 

MUCOUS   COLITIS. 
Etiology. — This   affection    regularly   occurs    in   neuras- 
thenic and  hysterical  patients.     Over  80  per  cent,  of  cases 
occur  in  women,  especially  in  those  who  have  suffered  from 


MUCOUS   COL/T/S.  449 

uterine  disease  or  from  dyspepsia.  It  is  essentially  a  dis- 
ease of  adult  life,  but  a  few  cases  occur  in  children.  It  is 
frequently  associated  with  gastroptosis  and  a  sagging  of  the 
large  intestine  (coloptosis),  and  in  many  of  the  cases  a  gastric 
anacidity  exists.  Synonyms:  Mucous  colic ;  Membranous 
colitis;   Mucous  diarrhoea  ;   Membranous  enteritis. 

Patholog-y. — There  are  no  evidences  of  inflammation, 
but  the  disease  seems  to  be  due  to  a  derangement  of  the 
mucous  follicles  of  the  colon.  The  exact  nature  of  the  dis- 
ease is,  however,  unknown. 

The  symptoms  appear  in  attacks  characterized  by  severe 
colicky  pain  with  tenderness  over  the  abdomen,  followed  by 
the  passage  of  mucus  in  flakes  or  strings  or  as  casts  of  the 
lining  of  the  bowel.  Mucus  is  not,  however,  passed  with 
every  paroxysm.  The  attacks  may  last  for  several  days  or 
weeks  ;  they  may  be  produced  by  errors  in  diet  or  by 
mental  worry,  and  they  often  occur  in  the  early  morning 
hours.  The  strings  of  mucus  frighten  the  patients  into  the 
belief  that  the  "  lining  of  the  bowel  is  ulcerated  and  is 
coming  away,"  so  that  they  become  hysterical  and  hypo- 
chondriacal. Between  the  attacks  the  symptoms  of  neur- 
asthenia are  regularly  present ;  they  become  more  marked 
before  and  during  the  paroxysms.  Symptoms  due  to  gas- 
troptosis and  to  gastric  atony  are  almost  regularly  present, 
and  there  may  be  the  symptoms  of  anacidity. 

The  course  of  the  disease  is  often  chronic,  the  attacks 
recurring  at  intervals  for  years. 

The  diagnosis  is  easily  made  if  the  mucus  be  not  mis- 
taken for  other  substances,  such  as  intestinal  parasites  and 
shreds  of  undigested  food.  The  long  continuance  of  the 
disease,  the  absence  of  fever,  and  the  exciting  role  played 
by  neurasthenia  and  the  emotions  serve  to  distinguish  the 
disease  from  diseases  of  an  organic  basis.  If  due  to  an  or- 
ganic basis,  mucus  is  regularly  present  in  the  wash-water  of 
an  intestinal  irrigation,  while  in  the  purely  neurotic  form  the 
bowel-washes  are  clear  between  the  attacks. 

The  prognosis  is  good  if  the  neurasthenia  can  be  relieved. 

Treatment  consists  primarily  in  the  cure  of  the  neuras- 
thenia. The  Weir  Mitchell  rest-cure  should  be  tried  in 
29 


450      M.t\L:u.  OF  THE  practice  of  medicixe. 

obstinate  cases,  while  in  all  instances  the  nutrition  should  be 
improved  in  e\'ery  way.  Forced  feeding,  especially  by  cream 
and  cod-liver  oil,  is  often  beneficial,  and  it  can  be  said  that 
tlie  prognosis  is  good  if  the  patient  can  be  made  to  gain  in 
weight.  Gastroptosis  and  atony  require  their  especial  treat- 
ment. If  there  be  coloptosis,  a  tight-fitting  supporting  belt 
should  be  advised. 

Morphine  is  not  to  be  used  during  a  paroxysm,  for  fear 
of  the  habit  being  formed.  High  enemata  of  w-arm  salt-solu- 
tion (3j  :  Oj)  ma>-  be  given  ever\-  day  to  cleanse  the  colon  and 
to  bring  awa\'  the  mucus.  At  least  two  quarts  of  the  solution 
should  be  allowed  to  enter  the  bowel  slowh',  the  patient 
lying  on  the  left  side  with  the  hips  elevated.  Astringent  and 
irritating  enemata  should  not  be  used. 

DIARRHOEAL  DISEASES  OP  CHILDREN. 
General  Etiology. — Diarrhoeal  diseases  occur  with  espe- 
cial frequency  among  artificially  fed  children  between  the 
ages  of  six  and  eighteen  months,  and  tenement-house  and 
asylum  children  are  more  apt  to  be  attacked.  Owing  to 
the  small  size  of  the  child's  stomach  and  to  the  deficiency 
in  the  saliva  and  in  the  proper  acidit)'  of  the  gastric  secre- 
tions, dietetic  errors  result  in  graver  consequences  than  in 
adults.  The  food  may  be  given  too  freely  or  at  irregular 
intervals,  or  the  child  may  partake  of  food  suitable  only 
for  adults,  and  the  result  of  these  dietetic  errors  is  intensi- 
fied by  teething  and  by  hot  weather.  Decomposed  milk 
teeming  with  bacteria  is  perhaps  the  most  common  cause 
of  infantile  diarrhcea.  The  relation  of  bacteria  to  the  diar- 
rhoeal affections  of  children  has  received  careful  attention. 
The  healthy  stools  of  children  contain  a  number  of  micro- 
organisms, the  most  important  of  which  are  the  bacterium 
coli  commune  and  the  bacterium  lactis  aerogenes,  the  latter 
being  present  only  after  a  milk  diet.  These  two  bacteria 
are  alone  constantly  present.  In  infantile  diarrhoea  there 
appear,  in  addition  to  the  above-mentioned  bacteria,  a  great 
number  of  micro-organisms,  as  many  as  fort)'  varieties  hav- 
ing been  described.  Acknowledging  that  these  diarrhoeal 
diseases  have   a   bacterial  origin,  no  one  germ  can   be  re- 


nrARh'IKKAf.    DISEASES    OE  CIIIf.DR EN.  45  I 

gardcd  as  the  specific  cause,  but  a  large  number  of  different 
kinds  are  concerned. 

Classiflcation, — Three  distinct  forms  of  acute  infantile 
diarrhoea  arc  to  be  described:  I.  Acute  dyspeptic  diar- 
rhoea ;  2.  Acute  entero-colitis ;  3.  Cholera  infantum. 

Acute  Dyspeptic  Diarrhcea. 

Acute  dyspeptic  diarrhcea,  which  is  caused  by  the  irrita- 
tion of  undigested  or  tainted  food,  is  due  to  increased  in- 
testinal peristalsis. 

Symptoms. — The  stools,  which  are  rarely  more  frequent 
than  five  or  six  in  the  twenty-four  hours,  consist  of  lumpy 
masses  of  undigested  milk  or  food.  They  are  not  watery, 
and  they  contain  no  mucus.  Their  color  is  yellow,  mixed 
with  green,  usually  changing  to  green  on  exposure  to  the 
air.  There  may  be  vomiting  of  food  and  of  mucus.  Col- 
icky pain  usually  precedes  each  stool,  and  the  abdomen 
may  be  distended  with  gas.  Convulsions  or  carpopedal 
spasms  may  occur  in  nervous  children.  In  mild  cases 
there  may  be  no  fever,  but  in  the  severer  forms  and  in  the 
case  of  children  naturally  feverish  the  temperature  may 
reach  104°  or  even  105°  F.  The  attack  usually  terminates 
when  the  intestine  has  been  relieved  of  its  irritating  con- 
tents ;  it  may,  however,  prove  fatal  in  sickly  children.  In 
hot  weather  and  in  neglected  cases  the  disease  may  develop 
into  entero-colitis. 

Treatment. — The  bowels  should  be  moved  freely  by 
castor  oil  or  calomel,  even  if  the  condition  of  diarrhoea 
persist.  Food  should  be  withheld  for  a  time  until  the 
stomach  is  settled,  but  cracked  ice  or  cool  water  may  be 
given.  After  the  bowels  have  been  moved  by  medication, 
bismuth  and  chalk  mixture  may  be  given. 

Acute  Entero-colitis. 
Acute  entero-colitis  is  the  ordinary  form  of  summer  diar- 
rhoea in  children.  It  is  the  dreaded  scourge  of  tenement- 
house  children  in  their  second  summer,  and  it  often  appears 
as  a  sequel  to  the  specific  diseases  of  children.  The  ileum 
and  the  colon  are  the  seat  of  a  catarrhal  inflammation,  the 


45-        M.lXL'.iL    OF   THE    PKACTICE    OF  MEDICIXE. 

follicles  being  especially  involved,  and  frequently  ulcerated, 
so  that  the  name  "  follicular  enteritis  "  or  "  follicular  dysen- 
tery "  is  sometimes  applied  to  these  cases.  In  severe  cases 
the  inflammation  may  be  of  the  pseudo-membranous 
variety. 

Symptoms. — The  disease  usually  follows  acute  dyspeptic 
diarrhcea.  The  general  condition  of  the  child  becomes 
worse.  The  temperature  rises  and  remains  constantly  high, 
although  extreme  hyperpyrexia  is  but  seldom  observed.  The 
stools  become  small  in  size,  vary  between  twelve  and  thirty 
in  the  twent)'-four  hours,  contain  a  large  quantity  of  mucus 
frequently  mixed  with  blood,  and  are  acid  and  offensive.  They 
may  be  passed  painlessly,  or  with  straining  and  tenesmus 
if  the  rectum  be  involved,  or  colicky  pain  may  precede  the 
movement.  Flatus  is  usually  passed  in  considerable  amount, 
and  the  abdomen  is  distended,  hard,  and  usually  tender  along 
the  line  of  the  colon.  Vomiting  may  occur,  but  it  is  rarely 
a  marked  feature  of  the  disease.  The  attack  may  last  for 
several  weeks  and  may  terminate  by  recovery  or  by  death 
from  inanition  and  exhaustion,  or  the  affection  may  become 
protracted.  In  this  form  the  acute  symptoms  disappear, 
but  the  diarrhoea  continues  and  nutrition  does  not  improve. 
From  this  subacute  enteritis  the  child  may  convalesce  in 
from  six  to  eight  weeks,  or  the  disease  may  become 
chronic. 

In  some  cases  of  entero-coHtis  the  follicular  glands  of  the 
colon  are  extensively  involved,  leading  to  the  symptoms 
frequently  spoken  of  as  the  "acute  dysentery  of  children." 
The  onset  is  sudden,  with  fever,  convulsions  in  the  severer 
forms,  and  frequent  small  passages  almost  entirely  com- 
posed of  mucus  and  blood,  and  not  containing  feces.  There 
are  incessant  abdominal  pain  and  rectal  tenesmus.  In  mild 
cases  the  bowels  can  be  opened  within  two  or  three  days 
by  castor  oil,  and  recovery  rapidly  ensues ;  but  if  the 
bowels  cannot  thus  be  moved,  the  case  is  apt  to  continue 
from  three  to  six  weeks,  or  even  to  become  chronic. 

There  is  a  rare  form  of  entero-colitis,  of  great  severity, 
characterized  by  high  fever,  dysenteric  symptoms,  convul- 
sions, stupor,  and  collapse. 


DIARRIKBAL   DISEASES   OF  CHILDREN.  453 

Treatment. — Attention  to  the  proper  feeding  of  the  child 
is  of  the  utmost  importance.  The  diet  should  consist  of 
sterilized  or  peptonized  milk  or  of  albumin-water.  Cream 
and  water  are  often  better  borne  than  milk.  After  the  irri- 
tating cause  has  been  removed,  bismuth  and  chalk  mixture 
should  be  given,  to  whicli  any  of  the  intestinal  antiseptics 
may  be  added.  Of  these,  bismuth  salicylate,  bismuth  sub- 
gallate,  and  salol  are  perhaps  the  most  reliable.  Large 
enemata  of  salt-solution  (.tJ  :  Oj)  should  be  used  to  flush  out 
the  colon  ;  they  are  of  the  greatest  service.  The  addition 
of  astringents  to  these  enemata  is  not  to  be  recommended. 
Should  dysenteric  symptoms  occur,  the  bowels  should  be 
opened  with  castor  oil,  and  this  medication  should  be 
repeated  every  other  day.  Medicated  enemata  may  in  these 
cases  be  used,  as  in  the  dysentery  of  adults. 

Cholera  Infantum. 

The  term  "  cholera  infantum  "  has  been  applied  loosely  to 
any  diarrhoea  of  childhood  with  vomiting  and  prostration, 
but  it  should  be  limited  to  a  special  group  of  symptoms 
resembling  cholera  morbus  of  the  adult.  The  term  beingf 
limited  in  this  way,  cholera  infantum  is  rather  a  rare  disease, 
occurring  in  only  2  or  3  per  cent,  of  the  summer  diarrhoeas 
of  children.  Cholera  infantum  is  essentially  a  bacterial  dis- 
ease, the  symptoms  being  due  to  poisoning  by  the  ptomaines 
generated  by  the  action  of  the  bacteria  upon  milk  or  other 
intestinal  contents,  although  no  one  organism  can  be  de- 
scribed as  a  specific  cause. 

Pathology. — There  is  an  acute  gastro-enteritis,  although 
the  appearances  of  inflammation  may  disappear  after  death, 
leaving  the  mucous  membranes  pale  and  sodden.  The 
lymph-glands  of  the  intestine  may  be  swollen,  and  in  rare 
instances  may  soften  and  break  down  to  form  follicular 
ulcers.  Various  micro-organisms  may  be  found  in  the  mes- 
enteric glands  and  in  the  lymphatic  vessels  of  the  intestinal 
wall. 

The  symptoms  of  cholera  infantum  may  begin  abruptly, 
or  there  may  be  a  preliminary  diarrhoea  for  several  days. 
The  first  regular  symptom  is  purging.     The  stools,  at  first 


454        MAXCAL    OF   THE   PRACTICE    OF  MEDICINE. 

acid  and  fecal,  later  become  alkaline,  serous,  and  either 
colorless,  brownish,  or  of  the  "  rice-water "  appearance. 
The  passages  are  abundant,  often  are  expelled  with  force, 
and  in  some  cases  amount  to  a  constant  discharge.  The 
purging  is  supposed  to  result  from  paresis  of  the  blood-ves- 
sels of  the  intestinal  wall  from  the  toxic  action  of  the  pto- 
maines, resulting  in  the  abundant  transudation  of  serum. 
There  is,  as  a  rule,  neither  abdominal  pain  nor  tenderness, 
although  in  some  cases  colicky  pain  may  precede  the  purg- 
ing in  the  earlier  stages  of  the  disease.  Vomiting  is  not  as 
constant  as  purging,  but  it  may  be  violent  and  incessant,  so 
that  no  food  can  be  retained.  The  vomited  matters  consist 
first  of  food ;  later  they  are  of  a  brownish  or  bile-stained 
serum,  and  may  be  like  rice-water.  The  skin  is  cool  and 
clamm}%  but  the  rectal  temperature  shows  an  increase  to 
103°,  105°,  or  even  107°  F.,  there  being  no  disease  of  in- 
fancy regularly  attended  by  so  high  a  temperature.  The 
pulse  is  rapid  and  thready.  The  skin  may  be  firm  and 
hard — a  condition  to  which  the  names  "sclerema"  and 
"  frozen  skin  "  have  been  applied.  The  appearance  of  the 
child  is  rapidly  altered  :  the  face  is  thin,  drawn,  and  of  an 
ashy  paleness,  the  eyes  are  sunken,  the  fontanelle  is  de- 
pressed, and  the  loss  of  weight  is  evident.  The  urine 
becomes  diminished  or  even  suppressed,  and  urjemic  symp- 
toms may  develop. 

Course  of  the  Disease. —  i.  A  considerable  number  of 
the  children  die  in  from  one  to  three  days,  from  exhaustion, 
collapse,  or  with  cerebral  symptoms.  These  "  hydrocepha- 
loid "  symptoms,  or  "  pseudo-hydrocephalus,"  consist  of 
drowsiness  merging  into  coma,  muscular  twitchings  or  con- 
vulsions, retraction  of  the  head,  and  subnormal  temperature 
or  hyperpyrexia;  the  respirations  become  shallow  and  ir- 
regular, and  may  be  of  the  Cheyne-Stokes  variety.  The 
pulse  becomes  irregular  and  flickering.  The  vomiting  and 
purging  usually  cease  for  some  hours  preceding  the  fatal 
termination. 

2.  Other  patients  begin  to  improve  in  from  twenty-four 
to  thirty-six  hours,  and  the  improvement  is  either  rapid  and 


DIARRIKI'.AL    DISEASES   OF  CI!  J  ED  REN.  455 

complete  or   is  complicated  by  a  recurrence  of  the  former 
symptoms.     Chronic  furunculosis  may  appear  as  a  sequel. 

3.  In  some  children  improvement  progresses  only  to  a 
certain  point,  but  the  child  still  continues  sick,  with  vomiting, 
diarrhoea,  and  prostration.  In  this  condition  the  child  may 
remain  for  weeks  and  then  slowly  recover  ;  or  the  symptoms 
may  continue,  prostration  and  emaciation  may  become  more 
and  more  marked,  and  the  child  may  ultimately  die  from 
marasmus. 

The  prognosis  is  always  serious,  especially  in  bottle-fed 
babies  and  in  asylum  and  tenement-house  children.  A 
guarded'prognosis  must  always  be  given,  however  mild  the 
case  may  appear  at  the  onset. 

Treatment. — The  most  important  indication  for  treat- 
ment is  the  reduction  of  the  hyperpyrexia.  This  should 
be  accomplished  by  baths  of  90°  F.  gradually  reduced  to 
80°  F.  by  the  addition  of  cool  water.  Irrigation  of  the 
stomach  and  the  colon  is  indicated  in  every  case,  to  remove 
toxic  products  and  to  supply  water  to  the  tissues.  For  the 
purging,  opium  is  almost  indispensable,  but  the  drug  should 
be  given  to  children  with  extreme  caution,  as  they  are  pecu- 
liarly sensitive  to  its  action.  Morphine  gr.  j^q-  is  a  fairly 
large  dose  for  a  child  of  one  year.  As  a  practical  rule, 
opium  should  not  be  given  to  babies  under  six  months  of 
age  unless  it  be  absolutely  necessary  to  do  so.' 

All  nourishment  should  be  discontinued  for  twelve  to 
eighteen  hours,  and  then  feeding  by  small  quantities  of  bar- 
ley-water, albumen- water,  or  expressed  beef-juice  ma}'  be 
permitted. 

Intestinal  antiseptics  should  be  given  if  they  do  not  add 
to  the  vomiting.  Of  these,  bismuth  salicylate  (gr.  v  q.  2  h.) 
is  perhaps  the  most  useful.  Small  doses  of  mercurial  prep- 
arations often  are  of  service  in  controlling  the  vomiting. 
Calomel  (gr.  jV).  mercury  with  chalk  (gr.  j^),  or  bichloride 
of  mercury  (gr.  ^-g-g")  may  be  given  in  these  doses  every  two 
or  three  hours  without  danger  of  salivation.  Stimulants 
may  be  given  if  indicated,  and,  should  collapse  appear, 
subcutaneous  injections  of  a  i  per  cent,  saline  solution 
(sterilized)  may  be  given  as  in  x\siatic  cholera.     Iced  drinks 


456       M.l.VL'AL    OF   THE    I'RACTICE    OF  MEDJCLXE. 

may  be  given  even  if  the}'  are  not  retained.  If  the  case  be 
protracted,  it  is  of  the  utmost  importance  to  move  the  child 
to  the  country,  where  the  air  is  cool  and  fresh.  These  httle 
patients  •  stand  travel  well,  and  the  improvement  is  often 
striking  within  a  few  hours  after  the  change  has  been  made. 
The  dietetic  rules  are  those  applicable  to  acute  entero-colitis. 

Cholera  iiifatituin  in  incat-fcd  children  presents  certain 
peculiarities  by  which  it  differs  from  cholera  infantum  of 
milk-fed  babies.  The  stools  are  not  as  watery,  as  frequent, 
nor  as  profuse  as  in  the  ordinary  cases,  but  are  grayish  or 
yellowish-green  and  highh'  offensive.  Tympanites  is  a  con- 
stant symptom,  but  vomiting  is  more  frequently  absent.  The 
general  symptoms  arc  those  of  sepsis,  and  death  usually  re- 
sults in  from  forty-eight  to  seventy-two  hours.  Mild  cases 
may  recover. 

CHOLERA  MORBUS. 

Etiolog-y  and  Synonym. — Cholera  morbus  is  most  com- 
mon in  young  adults  and  in  the  summer  months.  The 
attack  may  be  induced  by  improper  or  partially  decayed 
food,  by  unripe  fruit,  or  by  impure  drinking-water.  At 
times  the  disease  assumes  such  epidemic  proportions  that 
it  seems  as  though  some  specific  micro-organism  must  act 
as  the  exciting  cause.     Synonym  :  Cholera  nostras. 

Pathology. — The  lesion  consists  of  a  catarrhal  inflam- 
mation of  the  stomach  and  of  the  large  and  small  intes- 
tines. The  submucosa  is  infiltrated  to  some  extent  by 
fibrin,  serum,  and  round  cells,  and  the  intestinal  glands  are 
swollen.  It  is  impossible  to  differentiate  cholera  morbus 
from  Asiatic  cholera  except  by  post-mortem  examination, 
the  comma  bacillus  being  found  in  the  latter  disease. 

Symptoms. — The  attack  is  usually  sudden,  although  it 
may  be  preceded  by  oppression  and  by  vague  abdominal 
distress.  The  patient  is  usually  attacked  during  the  night 
or  the  early  morning.  There  are  nausea  and  faintness  with 
violent  and  incessant  vomiting,  the  ejected  matter  consist- 
ing at  first  of  food  and  later  of  fluid,  either  colorless  or 
tinged  with  bile.  Following  or  coincident  with  the  vomit- 
ing is  severe  purging.     The  stools  at  first  arc  feculent,  but 


COLITIS.  457 

later  become  watery  and  odorless  ;  they  consist  of  serum 
with  flakes  of  desquamated  epithelium,  giving  to  the  stools 
the  so-called  "  rice-water  "  appearance.  The  color  of  the 
passages  is  usually  greenish  or  yellowish,  and  the  fluid  is 
sufficiently  acrid  to  irritate  and  excoriate  the  anal  parts. 
Cramps  in  the  abdomen  cause  tearing,  lacerating  pain,  usu- 
ally referred  to  the  umbilicus,  but  in  some  cases  the  purging 
is  painless.  There  may  be  violent  muscular  cramps,  espe- 
cially in  the  calves  of  the  legs,  due  to  the  dryness  of  the  tis- 
sues. Prostration  appears  early  in  the  attack.  The  face  is 
drawn  and  anxious ;  the  pulse  is  rapid  and  thready ;  the 
skin  is  cold  and  clammy,  but  the  internal  temperature 
reaches   ioi°  or   I02°   F.,  or  even  higher  than  this. 

The  duration  of  the  attack  varies  from  a  few  hours  to 
several  days. 

The  prognosis  is  good.  The  disease  may,  however,  be 
fatal  in  debilitated  subjects,  so  that  the  whole  mortality  is 
between  2  and  3  per  cent. 

The  diagnosis  from  Asiatic  cholera  cannot  be  made  with 
certainty  without  bacterial  examination  of  the  stools. 

Treatment  is  entirely  symptomatic.  As  drugs  cannot 
be  retained  when  given  by  the  mouth  or  the  rectum,  hypo- 
dermic medication  alone  is  to  be  relied  upon.  Morphine 
in  gr.  y^  doses  should  be  given,  and  repeated  if  necessary, 
to  check  the  pain,  vomiting,  and  purging.  Hot  poultices 
applied  to  the  abdomen  afford  relief  For  the  attendant 
thirst  cracked  ice  may  be  allowed  if  it  does  not  increase 
the  vomiting.  It  is  well  to  give  no  food  by  the  mouth 
until  the  attack  is  well  over,  and  then  food  may  be  allowed 
in  small  quantities  at  first  and  at  frequent  intervals. 

COLITIS. 

Etiology. — Under  the  term  colitis  are  embraced  a  variety 
of  inflammations  of  the  large  intestine  from  the  caput  coli 
to  the  anus.  When  the  inflammation  involves  the  lower 
portion  of  the  bowel  and  is  accompanied  with  straining  and 
frequent  small  passages  containing  mucus,  it  is  commonly 
known  as  dysentery. 

Colitis   is  essentially  a  disease  of  the  tropics,  where  "it 


453        MAXr.lL    OF  THE   PRACTICE    OF  MEDICINE. 

destro)'s  more  lives  than  cholera,  and  it  has  been  more  fatal 
to  armies  than  powder  antl  shot  "  (Osier).  Under  imperfect 
hycjiene  sporadic  and  endemic  cases  occur  in  Northern  cities, 
and  even  epidemics  ma}'  occur,  but  with  improved  sanitation 
the  disease  is  much  less  common  than  formerly.  The  cx- 
citin^]^  cause  has  been  supposed  to  be  drinking-water  con- 
taminated by  animal  matter,  while  in  the  tropics  one  form 
of  dysentery  appears  to  be  due  to  infection  by  the  amoeba 
coli.  Colitis  attacks  patients  of  all  ages,  and  there  is  no 
racial  exemption.  The  majority  of  cases  occur  in  the  late 
summer  and  early  fall  months. 

Varieties. — The  following  \arieties  are  to  be  described : 
I.  Acute  catarrhal  colitis;  2.  Amcebic  or  tropical  colitis;  3. 
Acute  croupous  colitis ;  4.  Chronic  colitis. 

Acute  Catarrhal  Colitis. 

This  form  is  the  one  usually  seen  in  temperate  climates. 

Pathology. — The  intlamniation  is  limited  to  the  large 
intestine,  especially  to  the  sigmoid  flexure  and  the  rectum, 
but  the  lower  portion  of  the  ileum  may  also  be  involved. 
The  mucous  membrane  is  swollen,  congested,  and  covered 
with  tenacious  blood-stained  mucus.  The  solitary  glands 
are  prominently  enlarged,  and  in  severe  cases  may  ulcerate. 
In  the  gravest  form  of  the  disease  the  follicular  ulceration 
may  deepen  and  spread,  more  extensive  ulcerations  being 
formed.  In  children  the  inflammation  and  ulceration  of  the 
follicles  are  more  marked  than  in  adults,  so  that  the  disease 
is  often  spoken  of  as  "  acute  follicular  dysentery." 

The  symptoms  differ  according  to  whether  the  rectum 
or  the  upper  colon  be  involved. 

I.  If  the  rectum  be  involved,  as  it  is  in  the  vast  majority 
of  cases,  there  may  be  a  preliminary  diarrhoea  with  griping 
pains ;  in  other  cases  the  disease  begins  abruptly.  An 
initial  chill  is  rare.  Diarrhoea  is  usually  the  first  symptom. 
At  first  fecal  and  painless,  the  stools  change  their  character 
within  from  twenty-four  to  thirty-six  hours,  becoming  cha- 
racteristic of  the  disease.  The  dysenteric  stools  are  first 
composed  of  mucus  with  a  {^\s!  scybalous  fecal  masses,  but 
finally   they   consist   only   of   mucus   and    blood  ("  bloody 


COLITIS.  459 

slime  ").  The  presence  of  pus  in  the  stools  indicates  fol- 
licular ulceration.  The  stools  are  frequent,  varying  from  ten 
to  two  hundred  in  the  twenty-four  hours,  and  are  small  in 
quantity,  rarely  exceeding  half  an  ounce.  They  are  passed 
with  a  straining,  bearing-down  pain  referred  to  the  rectum. 
This  tenesmus  is  more  marked  during  and  after  a  move- 
ment, but  it  may  be  more  or  less  continuous,  amounting  to 
a  constant  desire  to  go  to  stool,  and  the  patient  may  com- 
plain of  burning  pains  referred  to  the  rectum.  Preceding 
each  stool  there  is  apt  to  be  severe  colicky  pain  in  the  abdo- 
men, with  possibly  some  tenderness  along  the  descending 
colon.  The  temperature  is  not  high,  varying  from  ioi°  to 
103°  F.  at  the  outset.  There  are  apt  to  be  nausea  and  vom- 
iting with  incessant  thirst.  Prostration  may  be  extreme. 
Strangury  may  attend  the  rectal  tenesmus,  and  in  severe 
cases  the  urine  may  contain  albumin  and  casts.  As  the  patient 
improves  the  number  of  passages  diminishes,  the  mucus  be- 
comes opaque  and  less  discolored  by  blood,  and  fecal  matter 
begins  to  be  passed.     Rectal  tenesmus  finally  disappears. 

2.  If  the  inflammation  involve  the  upper  colon,  and  not  the 
rectum,  the  clinical  picture  is  different.  The  patient  passes 
not  mucus  and  blood,  but  large,  watery,  feculent  stools  with- 
out tenesmus.  In  severe  cases  blood  may  be  admixed  with 
the  stools.  Colicky  abdominal  pain  precedes  each  passage. 
The  constitutional  symptoms  are  not  severe,  and  the  prog- 
nosis is  that  of  the  first  form.  In  children  this  form  is  ac- 
companied by  extreme  prostration  and  febrile  disturbance, 
so  that  the  case  may  be  mistaken  for  typhoid  fever. 

The  prognosis  for  the  attack  is  good  except  in  the  ex- 
tremes of  life.  If  the  bowels  can  be  opened  within  two  days 
by  castor  oil,  the  attack  will  probably  not  be  severe.  It  is 
possible  for  the  disease  to  run  into  a  chronic  form.  Peri- 
tonitis and  abscess  of  the  liver  rarely  occur. 

Diagnosis. — In  children  the  disease  may  be  mistaken  for 
intussusception,  while  in  adults-  cases  of  fecal  impaction  or 
of  cancer  of  the  intestine  are  frequently  treated  as  dysentery 

Tropical  or  Amcebic  Colitis. 
Pathology. — The  amceba  coli  or  amoeba  dysenteriae,  a 
one-celled  protoplasmic  organism  showing  active  amoeboid 


460        M.LVr.-iL    OF   THE   PRACTICE    OF  MEDIC  EVE. 

motion,  is  from  10  to  20  micromillimctcrs  in  diameter.  It 
has  been  pro\'en  to  be  the  inciter  of  d}'sentcr}-  in  tropical  and 
sub-tropical  countries,  and  it  is  not  iincommonh'  found  in 
the  Northern  United  States  and  in  Europe.  It  probably 
gains  access  to  the  bod}  bv  the  medium  of  drinking-water. 
The  large  intestine  is  involved,  particularly  the  descending 
colon,  but  the  lower  part  of  the  ileum  may  also  be  affected. 
The  lesion  consists  of  oedema  of  the  mucosa,  with  localized 
areas  of  cellular  infiltration  causing  little  elevations  upon 
its  surface.  These  elevations  become  necrotic  and  are  cast 
off,  exposing  a  yellowish-gray  gelatinous  mass  which  sub- 
sequent!)' sloughs,  leaving  an  ulcer  with  infiltrated  and  un- 
dermined edges  extending  through  the  submucosa  and 
even  to  the  serous  layer  of  the  colon. "  Extensive  under- 
mining of  the  edges  of  the  ulcerations  allows  of  the  forma- 
tion of  fistulous  tracts  bridged  over  by  apparently  healthy 
mucous  membrane.  The  colon  may  be  so  involved  that 
the  remaining  mucous  membrane  projects  like  little  islands 
from  the  surrounding  ulcerations.  The  disease  extends  by 
progressive  infiltration  and  ulceration  of  the  mucous  coat 
of  the  intestine,  and  in  severe  cases  large  areas  may  slough 
and  be  thrown  off  01  masse.  A  croupous  inflammation  of 
the  colon  complicates  amoebic  dysentery  in  some  cases. 
The  microscope  shows  a  notable  absence  of  the  products 
of  purulent  inflammation,  but  reveals  amoebae  in  large  num- 
bers in  the  floors  and  the  walls  of  the  ulcers.  Healing  of 
the  ulcerations  by  cicatrization  may  lead  to  subsequent 
stricture  of  the  intestine.  One-fifth  of  the  cases  are  com- 
plicated by  lesions  in  the  liver.  There  may  be  areas  of  necro- 
sis of  the  parenchyma  of  the  liver,  or  there  may  be  single  or 
multiple  abscesses,  consisting  of  necrotic  liver-tissue  with  a 
small  amount  of  pus.  Amoebae  are  constantly  found  in  the 
contents  of  the  abscesses.  Rupture  of  an  abscess  of  the  liver 
into  the  right  pleura  or  lung  is  not  infrequent. 

Symptoms. — The  onset  of  the  disease  is  usually  gradual, 
beginning  as  a  diarrhoea;  in  severe  cases,  however,  the  dis- 
ease may  begin  abruptly.  The  temperature  is  but  moder- 
ately raised,  if  at  all.  Pain  and  tenesmus  may  be  present 
at  the   outset   of  severe   cases,   but   they  are   not   constant 


COLITIS.  461 

throughout  the  disease.  The  principal  symptoms  are  diar- 
rhoea and  a  progressive  loss  of  flesh  and  of  strength.  At 
the  onset  the  stools  may  be  mucoid  and  blood-stained  as  in 
catarrhal  dysentery,  but  the  characteristic  stools  are  fluid, 
contain  mucus  and  possibly  blood,  are  of  a  yellowish-gray 
color,  and  in  them  are  to  be  found  actively  moving  amoebae. 
The  number  of  the  passages  varies  from  six  to  twelve  in  the 
twenty-four  hours.  The  diarrhoea  runs  an  irregular  course 
of  from  four  to  eight  weeks,  with  periods  of  temporary  im- 
provement. 

Prog-nosis. — Recovery  is  usually  slow  and  tedious  from 
anaemia  and  muscular  weakness,  and  convalescence  may  be 
interrupted  by  relapses.  The  disease  has  a  greater  mortality 
than  catarrhal  dysentery,  and  shows  a  tendency  to  become 
chronic.  Death  may  result  from  the  severity  of  the  local 
inflammation,  from  exhaustion  in  the  prolonged  cases,  or 
by  reason  of  the  liver   complications. 

Acute  Croupous  Colitis. 

This  form  of  colitis  may  occur  in  a  primary  form  or  may 
appear  as  a  terminal  complication  of  chronic  heart  disease, 
of  chronic  Bright's  disease,  of  profound  cachectic  states,  or 
of  lobar  pneumonia. 

Pathology. — The  colon  is  thickened  and  infiltrated  by 
fibrin,  serum,  and  pus-cells,  so  that  the  mucosa,  from  the 
ileo-caecal  valve  to  the  rectum,  appears  as  a  yellowish  exu- 
date without  trace  of  glandular  structures.  In  mild  cases 
the  tops  of  the  folds  of  the  colon  are  covered  with  a  thin 
yellowish  or  grayish  pellicle.  The  mucosa  thus  infiltrated 
undergoes  necrosis,  and  sloughs,  leaving  large  irregular 
ulcers  which  may  involve  the  submucosa  and  even  the  mus- 
cular wall.  Perforation  of  the  ulcers  is  not  uncommon.  In 
some  cases  the  lower  portions  of  the  colon  alone  are  in- 
volved. Peritonitis  may  complicate  the  disease  even  with- 
out actual  rupture,  and  ulcer  of  the  liver  may  result  from 
infective  thrombosis  of  one  of  the  mesenteric  veins.  Should 
the  patient  recover,  the  ulcerations  will  cicatrize  and  stricture 
of  the  intestine  may  result ;  but  the  healing  of  the  ulcers 
is  very  slow,  and  in  many  cases  chronic  ulcerations  are  left. 


462        M.l.VC.-iL    OF  THE   PRACTICE    OF  MEDICINE. 

The  symptoms  of  acute  croupous  colitis  resemble  those 
of  the  catarrhal  form,  but  are  more  severe.  If  the  rec- 
tum be  iiuolved,  tormina  and  tenesmus  are  extreme,  the 
stools  are  numerous,  are  composed  of  mucus,  blood,  pus, 
and  shreds  of  sloughing  membrane,  the  temperature  is 
high,  prostration  is  extreme,  and  the  patient  is  seriously  ill 
from  the  onset.  If  the  rectum  be  not  involved,  there  is  no 
tenesmus;  the  stools  are  diarrhoeal  in  character,  contain 
blood,  pus,  and  shreds  of  membrane,  and  are  accompanied 
by  severe  abdominal  pain.  The  constitutional  symptoms 
are  severe,  closely  resembling  those  oi  t\'phoid  fever. 

In  the  secondary  cases  the  patient  is  already  ill  from  the 
primary  disease,  so  that  the  course  of  the  dysentery  is  in- 
sidious. There  is  usually  a  moderate  diarrhoea,  with  the 
occasional  passage  of  blood  and  mucus. 

The  prognosis  of  croupous  colitis  is  exceedingly  grave. 
Death  may  result  from  the  severity  of  the  inflamma- 
tion, from  peritonitis  or  perforation,  or  from  abscess  of 
the  liver  ;  or  the  patient  may  pass  into  the  typhoid  condi- 
tion or  may  die  exhausted.  Should  the  patient  recover 
from  the  acute  attack,  the  condition  may  become  chronic. 

Complications. — The  course  of  the  disease  may  be  com- 
plicated by  septic  arthritis,  endocarditis,  pericarditis,  pleu- 
risy, and  pyaemia.  Peripheral  neuritis  with  paraplegia  is 
a  rare  complication.  The  occurrence  of  pylephlebitis  and 
abscesses  in  the  liver  has  already  been  alluded  to.  Chronic 
nephritis  has  in  some  cases  followed  the  disease. 

Treatment  of  Acute  Colitis. 
Of  the  Catarrhal  Form. — The  patient  should  be  put  to 
bed,  no  matter  how  trifling  the  attack  may  seem,  and  should 
be  kept  on  a  milk  or  liquid  diet.  It  is  important  that  the 
bowels  should  be  moved  at  the  beginning  of  the  attack, 
castor  oil  being  the  preferable  laxative.  An  estimate  of  the 
probable  duration  can  often  be  made  with  reasonable  accu- 
racy by  the  promptness  of  the  response  to  the  laxative 
remedies.  The  bowels  should  be  opened  every  second  day, 
if  possible.  Opium  should  be  given  by  the  mouth  or  by 
suppository,    to    control    the    tormina    and    the    tenesmus. 


COLJ'l'IS.  463 

Much  relief  is  often  afforded  by  rectal  medication.  y\n 
enema  of  hot  starch-water  containinc^'  from  10  to  15 
drops  of  laudanum  may  be  given  after  every  jjassage.  As 
the  enemata  are  seldom  retained  for  any  length  of  time, 
poisoning  is  not  likely  to  occur.  Suppositories  containing^ 
grain  of  cocaine  hydrochlorate,  or  injections  of  from  5  to 
10  drops  of  a  4  per  cent,  solution  of  the  drug,  are  ser- 
viceable in  mitigating  the  pain,  but  the  absorptive  power 
of  the  rectum  is  so  great  that  toxic  symptoms  may  occur 
unless  the  case  is  watched  with  care.  Quinine  (gr.  x-xv 
daily)  should  be  given  if  there  be  a  malarial  history.  Bichlo- 
ride of  mercury  (gr.  j^q)  may  be  given  every  two  hours, 
and  large  doses  of  bismuth  subnitrate  (.^j  q.  2  h.)  are  often  of 
great  service.  Astringent  rectal  injections  are  not  recom- 
mended in  acute  cases. 

In  severe  cases  ipecacuanha  may  be  given  in  large  doses. 
This  drug,  without  doubt,  is  of  great  service,  especially  in 
the  cases  occurring  in  the  tropics.  A  hypodermic  injection 
of  morphine  should  be  given,  followed  in  half  an  hour  by 
from  20  to  40  grains  of  powdered  ipecacuanha  in  capsule. 
A  second  injection  of  morphine  should  be  given  if  vomiting 
threaten.  No  food  should  be  given  for  six  hours  after  the 
dosage.  If  vomiting  occur,  the  dose  may  be  repeated  with- 
in a  few  hours. 

Amoebic  Colitis. — Besides  the  above-mentioned  treatment, 
colon-irrigation  of  quinine  (i  :  2500)  may  be  used,  the 
amoebae  being  rapidly  killed  by  the  drug.  Medication  should 
be  continued  in  these  cases  until  the  amoebae  are  no  longer 
present  in  the  stools. 

For  cro7ipo7is  colitis  the  treatment  is  that  of  the  catarrhal 
form,  except  that  opium  is  required  in  larger  doses,  and 
stimulants  are  needed  to  support  the  strength  of  the  patient. 
Should  extensive  ulceration  exist,  purgatives  must  be  admin- 
istered with  caution. 

Chronic  Colitis  and  Chronic  Dysentery. 

Etiology. —  Chronic  colitis  may  be  chronic  from  the  first, 
or  may  follow  an  acute  attack.  When  the  inflammation  is 
a  part  of  a  general  gastro-entero-colitis,  the  name  o(  chronic 


464        MAXCAL    OF  THE   PRACTICE    OF  MEDICLXE. 

colitis  is  given  to  it.  For  the  etiology  and  s)'mptonis  of  this 
difTused  inflammation  the  reader  is  referred  to  the  article  on 
Chronic   Enteritis. 

When  the  inflammation  involves  the  rectum  alone,  the 
clinical  picture  is  different,  and  the  condition  is  known  as 
chroiiic  dysentery.  The  following  article  embraces  only  this 
latter  form. 

Pathology. — The  mucosa  is  thickened,  pigmented,  and 
presents  an  irregular  puckered  surface.  The  submucosa 
and  the  muscular  coats  are  usually  hypertrophied,  and  the. 
lumen  of  the  colon  may  be  diminished.  Cystic  degenera- 
tion of  the  glandular  structures  may  be  visible  to  the  naked 
eye.  Ulcerations  are  generally  present  in  all  stages  of 
development ;  they  are  usually  pigmented. 

Symptoms. — Tormina  and  tenesmus  are  uncommon 
unless  during  acute  exacerbations.  The  stools  vary  from 
three  to  fifteen  in  the  twenty-four  hours,  and  are  not  always 
of  the  same  character;  they  may  be  composed  of  mucus, 
occasionally  stained  with  blood,  or  they  may  be  liquid  and 
frothy,  consisting  of  feces,  mucus,  and  undigested  food. 
Blood  and  shreds  of  tissue  are  not  common  except  during 
the  acute  exacerbations.  There  may  be  constipation  alter- 
nating with  diarrhoea.  From  time  to  time  will  appear  acute 
exacerbations  in  which  the  stools  assume  a  more  character- 
istic appearance  of  dysentery  and  are  accompanied  by  tor- 
mina and  tenesmus.  Pain  and  tenderness  along  the  colon 
are  usually  present.  The  patient  rapidly  loses  flesh  and 
strength  ;  the  tongue  resembles  raw  beef;  digestion  is  inter- 
fered with  ;  flatulence  is  common  ;  anremia  and  emaciation 
reach  finally  an  extreme  degree. 

Care  should  be  taken  to  exclude  carcinoma.  Digital  or 
instrumental  examination  6f  the  rectum  should  be  made  in 
every  doubtful  case. 

Prognosis. — The  course  of  chronic  dysentery  is  pro- 
longed for  months  or  possibly  for  years,  the  patient  usually 
dying  from  exhaustion  and  inanition. 

Treatment. — Proper  diet  is  of  prime  importance.  The 
patient  should  be  put  to  bed  and  be  given  a  milk  diet. 
Should  curds  appear  in  the  stools,  moat  broths  or  scraped 


Arpi-:xj)jcrj-js.  465 

beef  may  be  given,  and  only  such  food  be  allowed  as  may 
be  digested  thoroughly.  Inspection  of  the  stools  should 
then  govern  the  diet.  Colon-irrigation  should  be  employed 
daily,  simple  salt-solution  (.^j  ;  Oj)  being  the  preferable  solu- 
tion. Medicated  and  astringent  injections  are  painful,  and 
are  not  more  efficacious  than  simple  cleansing  solutions. 

APPENDICITIS. 
Etiology. — Appendicitis  is  more  common  in  the  young 
than  in  the  old,  one-half  the  cases  occurring  before  the 
twentieth  year.  Males  are  affected  in  three-fourths  of  the 
cases.  In  a  little  less  than  half  the  cases  hard  fecal  con- 
cretions or  foreign  bodies,  such  as  grape-seeds,  orange-pips, 
etc.,  are  found  in  the  diseased  appendix;  on  this  point,  how- 
ever, statistics  are  misleading,  the  percentage  of  cases  in 
which  concretions  are  found  being  estimated  as  low  as  6 
per  cent,  by  some  observers,  while  the  concretions  are  said 
to  be  present  in  10  per  cent,  of  presumably  healthy  appen- 
dices. The  question  as  to  whether  foreign  bodies  and  con- 
cretions can  originate  an  attack  of  appendicitis  is  still  un- 
answered. It  would  seem,  however,  that  foreign  bodies, 
concretions,  exposure  to  wet  and  cold,  injury  and  over- 
straining, and  previous  inflammations  of  the  appendix  or 
the  narrowing  of  its  lumen  by  stricture  or  by  twists,  render 
the  appendix  more  susceptible  to  the  infection  of  micro- 
organisms, so  that  they  may  be  considered  as  causes  pre- 
disposing to  a  bacterial  infection. 

Acute  Catarrhal  Appendicitis. 

Patholog-y. — The  mucous  membrane  lining  the  appendix 
is  in  a  condition  of  catarrhal  inflammation  ;  the  walls  are 
swollen  and  are  infiltrated  by  serum  and  leucocytes,  so  that 
the  appendix  is  enlarged  and  its  lumen  becomes  contracted, 
especiall}'  toward  the  cascal  end.  The  peritoneum  covering 
the  appendix  is  congested,  is  coated  with  fibrin,  and  is  ad- 
herent to  neighboring  peritoneal  surfaces.  In  this,  the  mild- 
est and  commonest  form  of  appendicitis,  there  is  no  general 
peritonitis,  no  abscess,  and  no  perforation. 

Symptoms  ma}'  begin  gradually  or  suddenly.     If  gradu- 

30 


466        AfJXL'AL    OF   TJIE   PRACTICE    OF  MEDICINE. 

ally,  there  is  a  preliminary  diarrhoea,  or  diarrhoea  alternating 

with  constipation,  and  a  pain  which 
is  either  of  a  colicky  character  or 
is  localized  in  the  right  iliac  fossa. 
Cases  with  a  sudden  onset  are  in- 
itiated by  a  chill  or  by  chilly  feel- 
ings. When  the  disease  has  de- 
veloped there  is  fever,  usually  of 

Fig.  44. — Cai;\rrli.il  aiipcMidicitis ;  1  .  •     ,  •.  _     • 1 

locahzed  fibrinou.  pcritonms:  no     moderate    intensity,    running    be- 

pus-format.on ;     no    general     peri-        tWCCn     IOI°     and     I03°    F.,     rCmain- 
tonitis.  •  /-  1  r  ^  1 

ing  for  three  or  lour  days  and 
then  slowly  subsiding.  It  is  of  the  greatest  importance  to 
keep  accurate  records  of  the  temperature  of  each  patient, 
as  it  is  impossible  at  the  onset  to  distinguish  between  the 
mild  and  the  severe  forms,  and  the  exact  diagnosis,  the 
presence  of  complications,  and  the  indications  for  operative 
interference  are  all  determined,  in  great  measure,  by  the  char- 
acter of  the  temperature  curve.  With  the  fever  there  are  head- 
ache, loss  of  appetite,  nausea  and  vomiting,  and  prostration. 

It  is  even  more  important  in  every  case  to  have  a  careful 
estimation  of  leukocytosis  made  daily.  In  the  catarrhal  form 
the  number  of  leukocytes  is   usually  under  12,000. 

Local  symptoms  consist  of  pain,  tenderness,  and  position 
in  bed. 

Pain,  which  is  localized  in  the  right  iliac  fossa,  may  be 
steady  or  paroxysmal.  Should  the  appendix  be  abnormally 
situated,  the  pain  may  be  felt  in  the  right  lumbar  region  or 
nearer  the  median  line  in  front.  In  some  cases  the  pain 
cannot  accurately  be  localized. 

Tenderness  is  usually  elicited  by  firm  continuous  pressure  at 
McBurney's  point,  situated  from  one  and  a  half  to  two  inches 
from  the  right  anterior  superior  spine,  on  a  line  drawn  between 
this  bony  prominence  and  the  umbilicus.  If  the  appendix  be 
displaced  behind  the  caecum,  tenderness  may  not  be  elicited 
at  McBurney's  point,  but  may  be  detected  by  vaginal  or  rectal 
examination  ;  hence,  in  doubtful  cases,  these  methods  of  ex- 
amination should  always  be  resorted  to.  The  thigh  is  usually 
flexed  to  relax  the  anterior  abdomen  ;  it  may  be  adducted 
from  irritation  of  the  obturator  nerve  within  the  pelvis. 


A/'P/'i/vn/c/r/s.  467 

Physical  Examination. — Tenderness  is  produced  by  pres- 
sure at  McBurney's  point  or  by  rectal  or  vaginal  examination. 
There  is  usually  considerable  rigidity  of  the  abdominal  wall 
in  the  right  iliac  region.  There  may  be  a  feeling  of  resist- 
ance in  the  right  iliac  region,  and  slight  dulness  on  percus- 
sion, but  no  defined  tumor  can  be  appreciated.  The  detec- 
tion of  resistance  and  dulness  on  percussion  depend  upon 
the  position  of  the  vermiform  appendix  (not  being  appre- 
ciable should  the  appendix  be  behind  the  caecum)  and  upon 
the  extent  of  the  localized  peritonitis.  Should  several  coils 
of  intestines  be  matted  together  and  adherent  to  the  appen- 
dix, the  resistance  and  dulness  may  be  as  well  marked  as  in 
cases  of  the  suppurative  form. 

Course  of  the  Disease. — After  from  two  to  four  days 
the  patient  begins  to  improve,  showing  that  the  case  is  one 
of  the  mild  form,  and  in  about  a  week  convalescence  is 
thoroughly  established.  Pain,  tenderness,  and  irregular 
action  of  the  bowels  may,  however,  persist  for  some  weeks, 
owing  to  the  resulting  peritoneal  adhesions,  and  relapses 
may  occur  at  any  time. 

Acute  Suppurative  Appendicitis  (Ulcerative 
Appendicitis). 
Pathology. — In  this  form  of  appendicitis  the  wall  of  the 
appendix  is  infiltrated  by  fibrin,  serum,  and  pus,  and  in 
severe  cases  the  wall  may  slough  in  some  part,  so  that  the 
contents  of  the  appendix  escape 
into  the  peritoneum.  The  ad- 
jacent peritoneal  surfaces  are 
inflamed,  coated  with  fibrin  and 
pus,  and  become  adherent,  so 
that  there  is  formed  a  cavity 
containing  pus.  This  circum- 
scribed intraperitoneal  abscess 
may  remain  localized  or  may  fig.  4S— Suppurative  appendicitis : 
rupture  into    the   general    peri-     "'"'^'"^  adhesions;   localized  intra- 

'■  01  peritoneal   abscess. 

toneal    cavity,  producing  acute 

peritoneal    septicaemia ;    or    diffuse    suppurative   peritonitis 

may  result  without  actual  rupture.     Suppuration  may  ex- 


468 


.U.l.VC.tL    OJ-    JI/Jl    PKACnCE    OF  MEDICI XE. 


tend  along  the  connective  tissue  in  the  mesentery  of  the 
appendix  and  invade  tlie  retroperitoneal  tissues.  This  for- 
mation of  an  extraperitoneal  abscess  is  not  common,  and 
occurs  only  in  connection  with  the  intraperitoneal  abscess 
previously  described  (Figs.  45.  46).  The  peritoneum  divid- 
ing the  intraperitoneal  from  the  extraperitoneal  abscess  ulti- 
mately becomes  absorbed,  so  that  one  large  abscess-cavity 
results. 

The  pus  may  be  abundant  and  creamy,  or  the  quantity 
ma\'  be  small  and  surrounded  by  a  large  amount  of  inflam- 
matory tissue.  The  pus  is  usually 
grayish  in  color,  exceedingly  offen- 
sive, and,  should  sloughing  of  the 
vermiform  appendix  occur,  may  be 
admixed  with  the  contents  of  the  in- 
testine. Bacterial  examination  usu- 
ally reveals  pure  cultures  of  the  ba- 
cillus coli  commune. 

The  position  of  the  abscess  varies 
according  to  the  position  of  the  ap- 
pendix. The  usual  situation  is  in  the 
angle  of  the  ileum  and  the  caecum, 
lying  on  the  psoas  muscle.  In  other 
cases  the  abscess  lies  behind  the  cae- 
cum or  extends  into  the  pelvis. 

Rupture  of  the  abscess  may  occur 
at  any  time,  either  into  the  perito- 
neum, the  intestine,  or  the  bladder, 
or,  less  frequently,  through  the  abdominal  wall,  the  pleura, 
the  portal  vein,  or  the  iliac  artery.  When  the  retroperito- 
neal tissues  become  infected,  the  so-called  "  pcrityphlitic  " 
abscess  may  burrow  under  the  iliac  fascia  and  appear  below 
Poupart's  ligament,  or  may  extend  to  the  perinephritic  tissues. 
Suppuration  may  extend  along  the  psoas  fascia  or  may  involve 
the  perirectal  connective  tissue.  Burrowing  through  the  ob- 
turator foramen,  the  pus  may  appear  as  a  gluteal  abscess. 

The  symptoms  begin  like  those  of  the  catarrhal  form, 
but  they  are  more  severe.  The  temperature  ranges  between 
102°  and   104°  F. ;  pain  and  tenderness  are  well  marked; 


Fig.  46.— Cross-section  of 
appendix  with  suppurative 
inflammation,  showing  ex- 
tension of  the  infection  along 
the  connective  tissue  of  the 
mesentery  to  the  retroperi- 
toneal connective  tissue,  and 
the  formation  of  an  extra- 
peritoneal abscess.  The 
peritoneum  separating  the 
intraperitoneal  from  the  ex- 
traperitoneal suppuration  is 
here  shown  intact ;  it,  how- 
ever, subsequently  disap- 
pears. 


APPKND/C/TfS.  469 

the  thigh  is  flexed  and  adducted;  the  bladder  and  the 
i-ectum   may  give  evidences  of  irritabihty. 

The  physical  signs  during  the  earher  stages  of  the  dis- 
ease depend  upon  the  position  of  the  abscess. 

{a)  If  the  abscess  be  in  the  inner  side  or  in  front  of  the 
caecum,  there  will  be  tenderness  in  the  right  iliac  fossa, 
especially  marked  over  McBurney's  point.  There  may  be 
some  bulging  in  the  right  iliac  fossa,  in  which  region  a 
percussion-note  of  dulness  is  obtained.  The  abdominal  wall 
on  the  right  side  is  rigid,  and  there  is  an  indistinct  tender 
mass  to  be  felt  in  the  region  of  the  appendix. 

{b)  If  the  abscess  be  small  and  be  situated  behind  the 
caecum  and  the  distended  intestines,  tenderness  on  palpation 
will  be  elicited,  but  no  tumor  can  be  detected,  although 
there  may  be  a  sense  of  resistance  to  palpation.  The  per- 
cussion-note is  tympanitic,  and  some  oedema  may  be  noticed 
in  the  right  lumbar  region. 

{c)  If  the  abscess  encroach  upon  the  pelvic  space,  the 
physical  signs  may  not  be  elicited  by  external  abdominal 
examination,  but  rectal  or  vaginal  examination  detects  the 
presence  of  the  abscess. 

Instead  of  the  disease  subsiding  in  three  or  four  days,  as 
does  the  catarrhal  form,  the  symptoms  become  aggravated. 
The  temperature  becomes  irregular  and  remittent,  and  septic 
symptoms  appear  on  the  third  or  fourth  day  and  are  strik- 
ingly developed  by  the  end  of  the  first  week.  In  some 
cases  there  are  added  the  symptoms  of  intestinal  obstruc- 
tion from  septic  paralysis  of  the  intestinal  wall. 

In  the  suppurative  form  the  leukocytes  vary^  between 
12,000  and  30,000,  with  about  18,000  as  the  average  of 
operable  cases. 

Physical  examination  by  the  seventh  or  tenth  day  may 
reveal,  by  palpation  through  the  abdominal  wall,  the  rectum, 
or  the  vagina,  an  indistinct  wave  of  fluctuation  in  the  tumor- 
mass.  The  fluctuation  is  most  marked  in  extraperitoneal 
abscesses,  and  is  detected  above  Poupart's  ligament  or  above 
the  crest  of  the  ilium.  The  abscess  may,  however,  be  small, 
and  may  be  in  a  locality  where  it  cannot  be  felt,  so  the 
diagnosis    may   still    be    doubtful.       The    aspirating-needle 


47 O        M.IXL'AL    OF  THE   PRACTICE    OF  MEDICLNE. 

should  never  be  used  for  diagnostic  purposes  unless  a 
marked  tumor  with  dulness  is  present  in  the  ca;cal  region, 
and  even  then  it  sliould  be  used  with  extreme  caution. 

Course  of  the  Disease. —  i.  Some  patients  gradually  re- 
cover. The  temperature  declines,  pain  and  tenderness  sub- 
side, and  the  physical  signs  clear  up.  These  are  the  cases 
of  mild  infection  in  which  the  peritoneal  exudate  is  chiefly 
fibrino-serous  without  much  admixture  of  pus,  so  that 
absorption  of  the  effusion  is  possible. 

2.  Other  cases  go  on  with  the  symptoms  of  sepsis  and  of 
a  localized  peritoneal  abscess. 

{a)  Some  cases  are  operated  upon  and  the  pus  is  evacuated. 


-■715 

Day  of 
Disease 

1 

2 

3 

4 

107° 

106° 

105° 

f 

104° 

■S 

. 

103<: 

•| 

r 

102° 

s 

A 

/ 

101° 
100° 

y' 

y 

: 

: 

Fig.  47. — Suppurative  appendicitis  :  rupture  of  abscess  into  peritoneal  cavity  ;  acute 
peritoneal  sepsis. 

ij))  In  some  cases  the  abscess  ruptures.  If  the  rupture 
occur  through  the  abdominal  wall  or  into  the  bladder,  the 
rectum,  or  the  intestine,  the  pus  will  appear  externally,  the 
temperature  will  fall,  and  the  general  symptoms  will  im- 
prove. If  drainage  be  good,  a  spontaneous  cure  will  result, 
but  if  drainage  be  poor,  the  abscess-cavity  will  fill  up  again 
and  the  old  symptoms  will  reappear.  Fistulae  may  result, 
and  there  may  be  a  resulting  cystitis  which,  if  the  bladder 
be  perforated,  may  prove  fatal. 

{c)  Burrowing  may  occur,  so  that  pus  will  rupture  into 
distant  parts,  even  into  the  pleural  cavity. 


ArPENDIC/'J'/S. 


47^ 


id)  Acute  progressive  peritonitis  may  develop.  This  is 
the  greatest  danger,  and  usually  begins  in  the  second, 
third,  or  fourth  day,  before  the  limiting  adhesions  have 
become  firm  enough  to  prevent  general  infection  of  the 
peritoneum.  Spreading  abdominal  pain,  tympanites,  and 
an  increase  in  all  the  constitutional  symptoms  indicate 
the  onset  of  the  peritonitis.  In  some  cases  there  is  a  pro- 
gressive increase  in  the  size  of  the  tumor. 

{e)  The  abscess  may  rupture  and  discharge  its  contents 
into  the  peritoneal  cavity,  so  that  acute  peritoneal  sepsis 
may  result.  The  temperature  falls,  but  subsequently  rises 
to  a  higher  point  than  before,  and  collapse  symptoms  appear. 
Death  may  occur  in  from  twelve  to  fifteen  hours  from  col- 
lapse, with  high  ante-mortem  temperature,  or  the  symptoms 
of  a  general  peritonitis  will  develop  from  which  the  patient 
will  die  in  two  or  three  days  (see  Fig.  47). 

3.  The  course  of  the  disease  may  be  modified  by  compli- 
cations. Among  these  may  be  mentioned  thrombosis  of 
the  femoral  vein,  and  thrombosis  of  the  portal  vein  which 
may  be  infective,  leading  to  pyaemia  with  multiple  abscesses 
in  the  liver.  Pyaemia  or  septicaemia  may  develop  in  neglected 
cases. 

Gangrenous  Appendicitis. 

Under  the  above  heading  are  included  the  rather  rare 
cases  in  which  primary  gangrene  or  necrosis  of  the  appen- 
dix-wall occurs,  so  that  the  contents  of  the  appendix  are 
discharged  into  the  peritoneal 
cavity  before  there  is  time  for 
limiting  peritoneal  adhesions  to 
be  formed.  The  patient  usually 
has  suffered  from  previous  at- 
tacks of  catarrhal  or  suppurative 
appendicitis,  with  resulting  ad- 
hesions, so  that  the  appendix 
becomes  distorted  and  twisted. 
Usually  the  exciting  cause  is  a 
foreign  body  or  a  fecal  concre- 
tion which  enters  the  appendix 
and  induces  a  pressure-necrosis  on  its  wall.    There  maybe  a 


Fig.  48. — Gangrenous  appendicitis  ; 
sloughing  of  the  wall ;  escape  of  con- 
tents into  peritoneal  cavity  ;  absence 
of  limiting  adhesions. 


4/2      .i/.i.vr.i/.  (V'  r///-:  pkact/c/-:  of  medicixk. 

local  peritonitis,  but  no  adhesions  are  formed,  so  that  the 
sloughing  appendix  lies  free  in  the  peritoneal  cavity.  Acute 
peritoneal  sepsis  develops,  and  usuall>'  runs  a  fatal  course. 

The  symptoms  begin  like  those  of  the  suppurative  form, 
but  the  patient  is  evidently  more  sick.  Peritoneal  sepsis 
and  death  usually  result  before  a  tumor  can  be  appreciated. 

Pi'ognosis  of  Appendicitis. 

In  the  catarrlial  fonii  the  prognosis  is  good.  It  should 
be  remembered,  however,  that  the  appendix  is  left  adherent 
and  predi-sposed  to  recurrent  attacks. 

In  the  suppurative  form  the  prognosis  is  good,  de- 
pending less,  however,  upon  the  intensity  of  the  inflam- 
mation than  upon  the  skill  of  the  surgeon.  When  gen- 
eral peritonitis  occurs,  the  prognosis  is  most  unfavorable. 
Rupture  of  the  abscess  into  the  general  peritoneal  cavity 
is  almost  regularly  fatal.  Spontaneous  cure  ma\'  occur  by 
absorption  or  by  perforation  through  the  abdominal  wall 
or  into  the  bladder  or  the  rectum,  but  aside  from  these 
cases  the  prognosis  is  bad  unless  the  case  be  treated  sur- 
gically and  the  abscess-cavity  be  drained. 

Gangrenous  appetuiicitis,  unless  operated  upon  very  early 
in  the  course  of  the  disease,  before  actual  perforation  has 
occurred,  is  rapidly  fatal. 

Treatment  of  Appendicitis. 

No  disease  requires  more  judgment  for  its  proper  treat- 
ment than  appendicitis,  as  no  routine  plan  of  treatment  is 
applicable  to  all  patients.  In  every  case  a  surgeon  should 
be  called  into  consultation,  as  the  disease  is,  properly  speak- 
ing, a  surgical  one.  The  treatment  is  both  medical  and 
surgical. 

Medical  Treatment. — The  patient  should  be  put  to  bed, 
no  matter  how  mild  the  case  may  appear,  and  be  put  upon 
a  liquid  diet.  Opium  is  to  be  given,  to  quiet  the  patient 
and  to  allay  pain,  but  large  doses  to  the  point  of  semi- 
narcotization  are  not  to  be  recommended.  Cathartics  are 
absolutely  contraindicated,  because  of  the  danger  of  ruptur- 


APJ'ENDJCJ  y  y.s'  47  3 

ing  limiting  peritoneal  adhesions  by  the  increase  of  intes- 
tinal peristalsis.  The  bowels  should,  however,  be  moved 
every  second  day  by  enemata  of  tepid  water  containing  salt 
(3j  :  Oj).  An  ice-bag  should  be  applied  to  the  cascal  region, 
or  a  Leiter  cold  coil  may  be  used.  Hot  poultices  are  not 
recommended. 

Surgical  treatment  consists  in  evacuation  of  the  pus, 
removal  of  the  diseased  appendix,  and  drainage  of  the  ab- 
scess-cavity. 

Operative  interference  is  indicated  under  the  following 
conditions:  (i)  In  catarrhal  appendicitis  with  severe  con- 
stitutional symptoms,  especially  if  the  attack  be  recurrent ; 
(2)  whenever  symptoms  of  pus-absorption  are  present, 
whether  the  tumor  can  be  felt  or  not ;  (3)  whenever  the 
patient  is  more  than  ordinarily  sick,  and  does  not  seem  to  be 
standing  the  disease  well;  (4)  should  septicaemia  develop; 
(5)  in  cases  of  spreading  peritonitis;  (6)  in  case  of  rupture 
and  peritoneal  sepsis ;  (7)  in  case  of  burrowing  of  the  ab- 
scess ;  (8)  in  all  cases  in  which  a  tumor  presents  itself;  (9) 
in  case  of  rupture  into  the  bladder,  the  intestine,  or  the 
rectum,  the  drainage  being  imperfect;  (10)  whenever  there 
is  an  increasing  leukocytosis.  If  the  leukocytes  vary  between 
15,000  and  18,000,  the  case  should  be  closely  watched,  but 
not  necessarily  operated  upon.  When  leukocytosis  amounts 
to  18,000  or  over,  an  operation  is  indicated. 

Chronic  Appendicitis. 

This  form  of  appendicitis  occurs  in  patients  who  have  had 
previous  attacks  of  acute  inflammation  of  the  appendix. 

Pathology. — The  appendix  is  usuall}'  enlarged  and  of  a 
sausage  shape.  Its  walls  are  thickened,  the  outlet  is  ste- 
nosed,  and  its  cavity  is  filled  with  mucus.  The  appendix 
may  be  sharply  bent  upon  itself  or  displaced.  The  peri- 
toneum adjacent  to  the  appendix  is  thickened  and  adherent. 
There  may  be  collections  of  serum  or  of  sero-pus  encapsu- 
lated by  the  peritoneal  adhesions. 

Symptoms. — In  some  cases  there  are  recurring  attacks 
of  acute  appendicitis,  in  the  intervals  of  which  the  patient 


474     .y.Lyr.iL  oj-'  tj/e  practice  of  medicine. 

is  perfectly  free  from   trouble.     To  these  cases  the  name 
"  recurring  appendicitis  "  is  frequently  applied. 

In  other  cases  the  patient  suffers  more  or  less  in  the 
intervals  from  the  chronic  inflammation  of  the  appendix;  to 
these  cases  the  terms  "  chronic  appendicitis  "  and  "  chronic 
relapsing  appendicitis  "  are  more  properly  applied. 

The  sy))iptovis  bctivcoi  acute  attacks  consist  of  localized 
pain  and  tenderness,  disturbances  of  digestion,  and  irregular 
action  of  the  bowels.  There  is  usually  progressive  loss  of 
flesh  and  strength.  Physical  examination  usually  reveals 
tenderness  over  McBurney's  point,  a  tumor  or  a  sense  of 
resistance,  and  a  dull  tympanitic  note  on  percussion. 

The  sy})iptoi)is  of  the  acute  exacerbations  resemble  those 
of  the  primary  attack.  These  acute  exacerbations  may 
occur  at  any  time,  so  that  the  patient  becomes  afraid  to 
travel  from  home,  being  apprehensive  of  the  increasing 
severity  of  future  attacks,  or  may  become  unable  to  pur-' 
sue  business  or  laborious  occupation. 

The  duration  of  the  disease  varies  from  one  to  ten  years  ; 
the  acute  attacks  vary  in  number  from  two  to  twenty  or 
thirty. 

The  prognosis  depends  upon  the  character  of  each  acute 
attack. 

The  treatment  is  surgical.  The  question  whether  to 
operate  during  an  interim  or  to  wait  until  the  symptoms 
of  an  acute  attack  call  for  surgical  interference  should  be 
left  to  the  surgeon  to  decide  upon  the  merits  of  each  indi- 
vidual case. 

ULCERATION   OF    THE    INTESTINE. 

The  following  intestinal  ulcerations  may  be  described : 
I.  Round  ulcer  of  the  duodenum  resembles  gastric  ulcer 
in  its  cause  and  appearance,  but  is  much  less  common 
(as  40  to  i).  The  ulcer  is  usually  single  and  situated  near 
the  pylorus.  Localized  peritonitis  with  adhesions,  local- 
ized peritoneal  abscess,  perforati\e  peritonitis,  and  hemor- 
rhage are  the  most  frequent  complications,  while  stenosis 
of  the  pylorus,  of   the   orifices  of   the   common   bile-duct, 


ULCERA'J'JON   OF    '////■:    /N77-:S77NF.  475 

or  of  the  pancreatic  duct  may  result  frf)m  cicatricial  con- 
traction.    Four-fifths  of  the  cases  occur  in  adult  males. 

The  symptoms  closely  resemble  those  of  gastric  ulcer. 
Pain  is  referred  to  the  right  hypochondriuni,  is  rarely  severe, 
and  appears  later  after  eating  than  does  the  pain  of  gastric 
ulcer.  There  may  be  only  irregular,  ill-defined  feelings  re- 
ferred to  the  hypochondriuni,  with  localized  tenderness. 
Dyspeptic  symptoms  and  vomiting  are  exceedingly  rare. 
Hemorrhage  occurs  in  one-third  of  the  cases.  The  blood 
may  be  vomited  or  be  passed  in  an  altered  condition  by  the 
bowel,  or  the  patient  may  die  before  the  blood  has  time  to 
appear  externally.  Many  cases  run  a  latent  or  obscure 
course,  and  in  these  cases  death  from  hemorrhage  or  from 
perforation  may  be  the  first  indication  of  serious  disease, 
although  in  the  latter  case  severe  continuous  pain  usually 
precedes  the  rupture  by  several  days. 

The  prognosis  is  more  serious  than  that  of  gastric  ulcer. 

The  treatment  is  that  of  ulcer  of  the  stomach. 

2.  Duodenal  tdceration  may  occur  after  extensive  burns 
of  the  skin.  The  duodenum  is  congested  and  ulcerated  in 
patches  of  an  irregular  form,  the  lesions  appearing  in  from 
seven  to  fourteen  days  after  the  injury.  The  exact  patho- 
genesis of  these  cases  is  unknown.  Hemorrhage  and  per- 
foration are  the  chief  symptoms,  and  the  patient  almost 
invariably  dies. 

3.  Embolic  ulcers  may  result  from  embolism  or  throm- 
bosis of  a  branch  of  the  mesenteric  artery.  The  emboli 
may  arise  from  endocardial  vegetation  or  from  atheroma  of 
the  aorta,  while  the  occurrence  of  thrombus  is  favored  by 
atheroma  of  the  mesenteric  artery  itself  The  mesenteric 
vessels  being  terminal  arteries,  embolism  or  thrombosis 
leads  to  hemorrhagic  infarction  of  a  section  of  the  intestinal 
wall,  which  rapidly  undergoes  necrosis.  The  peritoneum 
over  the  affected  area  is  inflamed  and  may  be  the  seat  of 
perforation,  and  the  intestine  itself  in  the  vicinity  is  con- 
gested and  infiltrated  with  blood.  The  diagnosis  is  to  be 
made  by  attention  to  the  following  points  :  (i)  The  presence 
of  a  cause  for  embolism  ;  (2)  the  presence  of  emboli  in  other 
organs ;  (3)  symptoms   of  intense   enteritis ;  (4)  symptoms 


476        MAXr.lL    OF   7UE   PKAC'JICK    OJ-    MEDICIXE. 

of  pcritonitis>.  If  the  embolus  be  septic,  exten.si\e  suppu- 
ration of  the  intestinal  wall  Avill  result.  Mnibolic  ulcers  of 
the  colon  are  exceedingly  rare. 

4.  Ulcers  due  to  avtyloid  degoicratioii  may  be  found  in  any 
part  of  the  intestinal  tract,  being  due  to  local  disturbances 
of  nutrition  consequent  upon  the  diminished  supply  of  blood 
that  necessaril}'  results  from  the  waxy  changes  in  the  wall 
of  the  terminal  arteries.  These  ulcers  show  no  disposition 
to  heal. 

5.  Catarr/ial  and  follicular  ulcers  result  from  acute  and 
chronic  enteritis.  Catarrhal  ulcers  are  usually  found  in  the 
colon,  either  as  slight  erosions  or  involving  large  areas  by 
their  extension  and  confluence.  The  floor  and  the  walls  of 
long-continued  ulcers  become  greatly  thickened.  The  natu- 
ral termination  is  by  cicatrization. 

Follicular  ulcers  may  be  found  in  either  the  large  or  the 
small  intestine.  They  are  of  round  shape,  with  undermined 
edges.  The\'  may  be  so  numerous  that  the  bowel  is  studded 
by  them.  Follicular  ulcers  may  extend  by  ulceration  of 
neighboring  parts  or  may  perforate.  Cicatrization  seldom 
results  unless  the  lesion  be  extensive. 

6.  Stercoral  Ulcers. — The  pressure  of  hardened  feces  leads 
to  necrosis  and  subsequent  purulent  infiltration  of  the  mu- 
cosa. Stercoral  ulcers  occur  in  situations  in  which  fecal 
accumulation  is  h'able  to  occur,  as  in  the  caecum,  the  rectum, 
the  flexures  of  the  colon,  or  above  the  point  of  stricture  in 
intestinal  ob.struction. 

7.  The  ulcers  of  typhoid  fever,  diphtheria,  variola,  and 
anthrax  have  elsewhere  been  described. 

8.  Tubercular  idccrs  are  of  common  occurrence.  They  may 
appear  as  a  primary  infection  from  the  ingestion  of  tubercu- 
lar meat  or  milk,  especially  in  children,  but  they  are  more 
common  as  the  result  of  secondary  infection  complicating  pul- 
monary or  genito-urinary  tuberculosis.  The  process  begins 
first  in  the  ileum,  extending  thence  to  the  re.st  of  the  small 
and  the  large  intestine.  Tubercles  first  develop  in  the 
solitary  or  agminated  follicles,  undergo  cheesy  degeneration, 
and  break  down  to  form  ulcers.  These  follicular  ulcers 
extend  by  suppuration  and  by  extension  of  tubercular  de- 


L7.CEA'.l7VOX   OF   TI/J'.    fXTKS'/fjVE.  477 

posits  along  the  line  of  the  lymphatic  vessels,  so  that 
"  girdle  "  ulcers  are  formed,  encircling  the  intestine  at  right 
angles  to  its  long  axis.  The  peritoneum  covering  the  site 
of  the  ulcer  is  studded  with  tubercles,  is  coated  with  fibrin, 
and  is  adherent  to  adjacent  surfaces.  Perforation  may 
occur;  it  is  usually  prevented,  however,  by  the  formation 
of  peritoneal  adhesions.  The  mesenteric  glands  are  al- 
most invariably  enlarged  and  tubercular.  The  girdle 
shape  of  the  ulcer  distinguishes  it  from  typhoid  ulcera- 
tion. A  differential  diagnosis  in  the  earlier  stages  can  be 
made  by  the  fact  that  in  typhoid  fever  ulceration  of  a  Peyer's 
patch  is  uniform,  whereas  in  tubercular  disease  separate 
follicles  are  involved,  while  others  entirely  escape.  Cicatri- 
zation is  rare,  but  it  is  possible. 

9.  Leiikceniic  ulcers  result  from  necrosis  of  lymphoid  de- 
posits in  the  wall  of  the  intestine.  They  are  rare,  however, 
except  during  the  course  of  acute  leukaemia. 

10.  Scorbutic  ulcers  may  follow  hemorrhages  into  the 
mucosa. 

11.  Syphilitic  ulcers  are  rare  in  the  small  intestine  except 
in  new-born  syphilitic  children.  Gummata  of  the  intes- 
tinal wall  may  occur,  and  ulcers  may  result  from  their 
breaking  down.  Syphilitic  ulceration  of  the  rectum  is  not 
uncommon,  especially  in  women  ;  it  leads  to  progressive 
fibrous  stricture. 

12.  Urcentic  ulcers  may  occur  with  advanced  nephritis  in 
several  ways  :  {a)  Ulceration  of  solitary  and  agminated  folli- 
cles, with  catarrhal  entero-colitis  ;  {b)  as  a  result  of  a  pseudo- 
membranous enteritis ;  {c)  gangrenous  ulceration  may 
occur. 

13.  Mercurial  ulcers  follow  pseudo-membranous  enteritis 
from  poisoning  by  mercury. 

14.  Cancerous  ulcerations  may  result  from  the  breaking 
down  of  submucous  nodules. 

15.  Ulceration  from  external  perforation  may  occur  from 
ulceration  and  erosion  of  new  growths  or  by  the  perforation 
of  a  neighboring  abscess  into  the  intestine. 

The  symptoms  of  ulceration  of  the  intestine  depend  upon 


478        MA.Vr.-tL    OF  THE   PKACTICE    OF  MEDIC/XE. 

the  position  and  extent  of  tlie  ulceration  and  upon  its  patho- 
logical character. 

Diarrhoea  is  a  frequent  s\-niptoni,  being  regularly  present 
with  ulcers  of  the  lower  portion  of  the  colon  and  the  upper 
portion  of  the  rectum.  Ulcers  limited  to  the  small  intestine, 
the  caecum,  and  the  ascending  colon  do  not  of  themselves 
cause  diarrhoea. 

Hemorrhage  varies  in  amount,  the  largest  hemorrhages 
occurring  with  duodenal  ulceration,  typhoid  fever,  and  per- 
foration from  without  the  intestine.  If  the  origin  of  the 
hemorrhage  be  in  the  upper  portion  of  the  intestine,  the 
blood  is  usually  dark  and  altered  and  mixed  with  feces ; 
heniatin-crystals  may  alone  be  detected. 

Pus  in  the  stools  is  rare  unless  from  ulceration,  and  hence 
its  presence  is  of  great  diagnostic  importance.  Large  evacu- 
ations of  pus  indicate  rupture  of  a  neighboring  abscess  into 
the  intestine.  Usually  the  quantity  of  pus  is  small,  necessi- 
tating for  its  detection  close  scrutiny,  and  even  microscopical 
examination,  of  the  feces.  Pus  with  blood  and  mucus  usu- 
ally indicates  dysentery  or  an  ulcerating  carcinoma  of  the 
colon  or  the  rectum.  Shreds  of  tissue,  if  proven  not  to  con- 
sist of  undigested  food,  afford  conclusive  proof  of  rapid  and 
extensive  ulceration.  Tubercle  bacilli  in  the  stools  are 
usually,  but  not  invariably,  found  in  cases  of  tubercular 
ulceration. 

Pain  is  frequently  absent.  It  may  be  of  the  nature  of  a 
colic,  or  there  may  be  steady  pain  due  to  a  complicating 
localized  peritonitis.  Tenderness,  which  may  be  constant 
over  a  small  area,  is  of  value  in  localizing  the  seat  of  ulcera- 
tion.    Tenesmus  occurs  only  if  the  rectum  be  ulcerated. 

Fever  depends  upon  associated  conditions.  Emaciation 
depends  upon  the  extent  and  pathological  character  of  the 
ulcers,  and  is  more  pronounced  when  the  small  intestine  is 
affected. 

Not  infrequently  ulcers  of  the  intestine  run  an  entirely 
latent  course,  and  are  unexpectedly  found  at  post-mortem 
examination. 

The  complications  of  ulceration  comprise  localized  peri- 
tonitis, peritoneal  abscess,  purulent  or  perforative  peritonitis, 


CANCER    0J<    'J-JIl-:    /N'/'ES'/VNE.  479 

and  hemorrhage ;  should  cicatrization  occur,  intestinal  ob- 
struction may  result. 

Treatment. — The  diet  should  be  easily  digestible,  nutri- 
tious, and  unirritating.  A  milk  diet  is  indicated  in  severe 
cases,  and  prolonged  rest  in  bed  may  be  necessary  to  accom- 
plish good  results.  For  ulceration  of  the  small  intestines 
antiseptics  by  the  mouth  should  be  given,  to  keep  the  intes- 
tinal tract  disinfected  so  far  as  possible.  Bismuth  salicylate 
and  subnitrate  (each  15  grains  every  three  or  four  hours) 
are  of  great  value,  but  salol,  bismuth  subgallate,  naphthalin, 
and  resorcin  may  be  used.  For  ulceration  of  the  colon 
large  injections  of  warm  salt-solution  are  to  be  given  to 
cleanse  the  bowels.  The  addition  of  astringent  or  irritating 
drugs,  such  as  nitrate  of  silver,  salicxdic  acid,  or  thymol, 
does  not  seem  to  increase  the  medicinal  value  of  these  in- 
jections, and  certainly  renders  them  painful  and  annoying. 

Ulceration  of  the  rectum  can  be  treated,  if  within  reach, 
by  the  methods  pursued  in  treating  external  ulcers, 

CANCER   OP    THE    INTESTINE. 

Carcinoma  of  the  intestine  usually  occurs  as  a  primary 
growth,  and  comprises  from  4  to  8  per  cent,  of  all  cases 
of  cancerous  disease.  Four  varieties  are  encountered,  which, 
in  order  of  frequency,  are  cylindrical-celled  epithelioma, 
encephaloid,  colloid,  and  scirrhus.  Growths  in  the  large 
intestine  are  nine  times  as  common  as  those  of  the  small 
intestine,  the  seats  of  selection  being  the  rectum  (80  per  cent, 
of  all  intestinal  cancers),  the  sigmoid  flexure,  and  the  caput 
coli.     Next  in  frequency  comes  cancer  of  the  duodenum. 

Patholog-y. — Scirrhus  usually  produces  a  hard  infiltra- 
tion of  the  intestinal  wall,  narrowing  the  lumen  of  the  gut. 
The  encephaloid  and  cylindrical-celled  epithelioma  form 
annular  constrictions,  large  fungoid  masses  projecting  into 
the  cavity  of  the  intestine,  and  are  very  prone  to  ulceration 
and  hemorrhage.  The  colloid  form  produces  a  gelatinous 
infiltration  of  the  intestinal  wall,  without  much  tendency  to 
ulcerate  or  to  cause  obstruction.  Secondary  deposits  are 
not  uncommon,  especially  in  the  liver,  the  general  rule  be- 
ing that  when  secondary  cancer  of  the  liver  develops,  the 


4S0        .U.I.Vr.lL    OJ-'    J  HE   rRACTlCE    OF  MEDICI  XE. 

primary  cancer  in  the  intestine  ceases  to  grow  and  often 
gives  no  further  s\-mptoms,  so  that  the  case  will  resemble 
on€  of  primary  cancer  of  the  liver. 

From'  the  ulceration  of  the  cancer  perforation  may  occur 
into  the  peritoneum  or  into  hollow  viscera,  forming  fecal 
fistuUv  ;  or  extensive  hemorrhage  may  result.  The  intestine 
becomesvmore  or  less  occluded,  the  obstruction  being  often 
rendered  more  complete  by  fecal  accumulation  at  the  [joint 
of  stricture. 

Cancer    of   the  Rectum. 

Symptoms. — Pain  is  usually  more  marked  than  that  pro- 
duced by  cancer  in  any  other  part,  excepting  cancer  of  the 
tongue.  The  pain  is  not  always  of  the  same  kind,  {a)  In  some 
cases  the  pain  is  the  same  as  that  produced  by  cancer  in  any 
other  part  of  the  bod}'- — dull,  boring,  and  continuous,  {p)  The 
pain  may  be  neuralgic,  and  is  due  to  pressure  on  the  sacral 
plexus.  These  cases  are  frequently  treated  for  sciatica. 
{c)  The  pain  may  be  due  to  obstruction  of  the  rectum,  being 
paroxysmal  and  straining  in  character.  These  cases  are 
often  treated  for  chronic  dysentery,  for  fecal  impaction,  or 
for  hemorrhoids.  Malignant  disease  of  the  rectum  should 
be  suspected  in  every  case  of  constipation  and  hemorrhoids 
in  an  old  person  whose  bowels  have  been  previously  regular. 

Hemorrhage  is  usually  in  small  amounts ;  it  is  brought 
on  by  straining  attempts  at  stool.  Occasionally,  however, 
the  bleeding  is  profuse. 

In  nearly  all  cases  there  is  an  irritating  discharge  which 
excoriates  the  anus  and  the  neighboring  parts.  Should  the 
sphincter  ani  be  relaxed,  as  often  happens,  the  condition  of  the 
patient  is  rendered  more  uncomfortable.  There  are  regularly 
changes  in  the  action  of  the  bowels  :  {a)  There  may  be  diar- 
rhoea accompanied  by  pain  and  tenesmus  ;  (/;)  the  stools  may 
be  deformed  by  being  forced  through  the  constricted  rectum, 
so  as  to  be  ribbon-shaped  or  as  small  in  diameter  as  a  lead- 
pencil  ;  (r)  there  may  be  constipation  with  symptoms  of 
intestinal  obstruction.  Should  the  obstructing  growth 
ulcerate,  the  con.stipation  will  suddenly  give  way.  Cancer- 
ous cachexia  intervenes,  and  the  symptoms  of  secondary 


CANCKK    OF   Tllli    JA'-J'/iST/NE 


481 


deposits  in  adjacent  viscera  or  in  the  liver  may  complicate 
the  latter  stages  of  the  disease. 

Physical  Examination. — There  may  be  a  hard  ring  felt 


Fig.  49. — Physical  examination  of  cancer  of  the  rectum 

two  or  three  inches  from  the  anus,  usually  just  large  enough 
to  admit  the  finger  (Fig.  49,  a).  In  some  cases  the 
bowel  is  invaginated,  so  that  the  ring  is  pushed  down  by 
the  accumulation  of  feces  above  (b),  and  the  orifice  of  the 
constriction  may  be  tilted  so  that  it  is  found  with  difficulty 
(c).  In  either  case  there  are  felt  projecting  into  the  rec- 
tum large  friable  masses  which  bleed  readily  (d),  or  ulcera- 
tions with  hard  edges  and  floor  may  be  detected  (e).  In 
cases  of  colloid  carcinoma  the  wall  of  the  rectum  loses 
its  soft,  velvety  feeling  and  becomes  dense  and  thick,  but 
no  obstruction  and  no  ulceration  can  be  appreciated  (f). 
In  examination  for  rectal  carcinoma  the  patient  should  stand 
up  and  bear  down,  to  bring  the  growth  within  reach.  If 
nothing  can  then  be  felt,  examination  under  an  anaesthetic 
is  indicated. 

Prognosis  and  Treatment. — An  early  diagnosis  should  be 
made  if  possible.  Neglected  cases  run  a  fatal  course  of  from 
two  to  four  years,  but  life  may  be  prolonged  by  an  early 
excision  of  the  neoplasm,  as  by  Kraske's  operation.  In 
some  cases  a  radical  cure  has  thus  resulted.  Lumbar  colot- 
omy  with  the  formation  of  an  artificial  anus  may  be  indi- 
cated to  relieve  the  constipation  and  to  modify  the  pain. 

Cancer  op  the  Caput  Coli. 
The  symptoms  of  cancer  of  the  caput  coli  begin  gradu- 
ally and  are  at  first  obscure.    There  is  a  gradual  loss  of  flesh 
and  strength,  with  varied  digestive  disturbances.     In  other 

31 


48j         M.l.VUAL    OF   THl:    PRACTICE    OF  MEDICINE. 

cases  pain  is  the  first  symptom  noticed.  The  pain  may  be 
dull  and  boring  or  sharp  and  colicky.  If  there  be  obstruc- 
tion, pain  is  increased  and  s}-mptonis  of  intestinal  obstruc- 
tion gradually  appear.  Physical  examination  reveals  a  tumor 
in  the  caecal  region — a  tumor  hard  and  irregular,  either 
globular  in  shape  or  ovoid,  its  long  axis  agreeing  with  the 
course  of  the  ascending  colon.  The  tumor,  which  is  usually 
adherent  to  the  posterior  abdominal  wall,  so  that  it  is  not 
apt  to  be  movable,  is  most  liable  to  be  mistaken  for  fecal 
impaction  or  for  a  chronic  appendicitis.  The  patient  be- 
comes cachectic,  loses  flesh  and  strength,  suffers  from  diar- 
rhoea or  constipation,  and  dies  exhausted  or  from  intestinal 
obstruction. 

Treatment  of  cancer  of  the  caput  coli  is  merely  palliative 
in  cases  in  which  the  diagnosis  is  made  too  late  to  allow  of 
resection  of  the  intestine. 

Cancer  of  the  Duodenum. 

Caticer  of  the  duodoiiim  usually  presents  itself  as  a  mova- 
ble tumor  which  cannot  be  differentiated  from  malignant 
growths  of  the  pylorus.  The  tumor  may  be  displaced  into 
the  lower  abdominal  region  by  reason  of  the  weight.  Dila- 
tation of  the  stomach  usually  results,  and  the  pancreatic 
duct  and  the  bile-ducts  ma)-  be  obstructed. 

The  treatment  is  palliative. 

Non-cancerous  Tumors  of  the  Intestine. 

Non-cancerous  growths  are  so  rare  that  they  possess  only 
pathological  interest. 

Mucous  polypi  may  occur,  especially  in  children  and  in 
the  rectum ;  or  there  may  be  found  pediculated  fibromata. 
Lipoma,  sarcoma,  lymphangioma,  and  myoma  have  been 
described. 

INTESTINAL    OBSTRUCTION. 

Etiology  and  Pathology. —  i.  Inlcnial  strangulation,  or 

"  internal  hernia,"  is  the  cause  in  one-third  of  the  cases,  and 

is  the  most  frequent  cause  of  obstruction  in  adults ;  70  per 

cent,  of  the  cases  occur  in  males.    The  strangulation  may  be 


/N77CS77N/1/.    OBS77x'UC770N.  483 

produced  in  various  ways  :  A  loop  of  intestine  may  be  con- 
stricted by  passing-  between  peritoneal  adhesions  or  by 
passing  through  apertures  in  the  mesentery  or  the  omen- 
tum, through  the  foramen  of  Winslow,  or  even  through  the 
diaphragm.  Should  the  tip  of  Meckel's  diverticulum  be 
adherent  to  the  mesentery  or  to  the  abdominal  wall,  a  ring 
will  be  formed,  through  which  a  coil  of  intestine  may  pass. 
In  90  per  cent,  of  all  cases  the  ileum  is  the  portion  of  the 
intestine  involved.  Strangulation  results  in  obstruction, 
ulceration,  sloughing,  and  eventually  in  perforation. 

2.  Intussusception^  or  invagination,  which  occurs  in  one- 
third  the  cases,  is  the  most  frequent  cause  of  obstruction  in 
children,  one-third  of  the  cases  occurring  during  the  first 
year,  and  one-half  of  the  cases  before  the  tenth  year.  This 
condition  arises  whenever  one  portion  of  the  intestine  slips 
into  an  adjoining  part  as  a  tuck  may  be  taken  in  the  finger 
of  a  glove;  it  appears  to  be  due  to  irregular  peristalsis,  the 
receiving  layer  being  drawn  up  by  contraction  of  the  lon- 
gitudinal fibres.  In  each  intussusception  three  layers  of 
intestine  are  brought  in  apposition  :  an  outermost  or  re- 
ceiving layer  (the  intussuscipiens),  the  middle  or  returning 
layer,  and  the  inner  or  entering  layer.  The  outer  and  mid- 
dle layers  are  in  contact  by  their  mucous  surfaces,  the 
middle  and  the  inner  by  their  serous  surfaces.  There  is 
thus  formed  a  longitudinal  tumor  varying  in  length  from 
several  inches  to  as  many  feet,  and  the  invagination  extends 
at  the  expense  of  the  outer  layer. 

The  intussusception  is  invariably  downward.  The  affected 
parts  become  swollen,  congested,  and  perhaps  ecchymotic. 
In  recent  cases  the  peritoneum  is  merely  congested  and  the 
intussusception  may  readily  be  reduced,  but  in  cases  living 
for  two  or  three  days  the  peritoneal  surfaces  become  so  agglu- 
tinated by  fibrinous  adhesions  that  reduction  is  no  longer 
possible.  The  invaginated  portion  may  slough  and  be  passed 
by  the  rectum,  so  that  spontaneous  cure  may  result.  Three- 
fourths  of  the  cases  of  intussusception  are  of  the  ileo-caecal 
variety,  in  which  the  valve  slips  into  the  large  intestine,  gradu- 
ally inverting,  appearing  at  the  rectum  in  extreme  cases.  In- 
tussusception of  the  ileo-caecal  variety  or  confined  to  the  large 


4S4      .u.i.vc'.i/.  (>/■'  /'///■:  PA'AC/vcF.   o/-'  .)//:n/c/.\/:. 

intestine  may  last  in  rare  instances  for  months  witlunit  i;iving 
rise  to  acute  s\-mptoms. 

3.  Volvulus,  or  twist  of  the  intestine,  is  the  cause  of  the 
obstruction  in  one-seventh  of  the  cases.  Two-thirds  of  the 
cases  of  volvulus  occur  in  men,  and  the  condition  is  most 
frequent  between  the  ages  of  thirty  antl  forty.  The  twist, 
which  is  usually  in  the  long  axis  of  the  intestine,  is  favored 
by  a  long  mesentery,  but  one  loop  may  be  twisted  around 
another  or  may  be  bent  sharply  upon  itself.  In  one-half  the 
cases  the  volvulus  occurs  in  the  sigmoid  flexure,  next  fre- 
quently in  the  Cciecal  region.  The  twisting  interferes  with 
the  circulation  of  blood  and  leads  to  necrosis  of  the  affected 
portion  of  the  intestine. 

4.  Acute  obstruction  from  strictures  and  tumors  may 
occur,  but  the  obstruction  is  more  apt  to  be  chronic  and 
progressive,  although  never  complete.  Narrowing  of  the 
lumen  of  the  intestine  may  be  due  to  the  following  condi- 
tions :  {a)  Congenital  stricture  as  the  result  of  fatal  peri- 
tonitis, in  which  case  the  obstruction  is  usually  in  the 
rectum  or  the  lower  ileum  ;  or  there  may  be  congenital 
malformation  resulting  in  imperforate  anus  or  rectum,  {b) 
Cicatricial  stenosis  may  result  from  previous  ulceration. 
{c)  New  growths  of  the  intestine,  especially  epithelioma,  {d) 
Compression  of  the  intestine  by  abdominal  or  pelvic  tumors, 
(r)  Contraction  of  inflammatory  exudate,  especially  with 
tubercular  peritonitis. 

5.  Obstruction  may  be  due  to  foreign  bodies  within  the 
intestine.  Gall-stones  may  enter  the  intestine  through  the 
duct,  or  there  may  have  been  a  communication  between  the 
intestine  and  the  gall-bladder.  Enteroliths  may  be  formed 
by  the  phosphates  of  lime  and  magnesia  being  deposited 
about  a  central  nucleus  ;  or  the  foreign  body  may  be  a 
tangled  mass  of  worms.  Fecal  accumulation  is  a  common 
cause  of  obstruction,  and  will  elsewhere  be  described. 

Symptoms. — The  three  cardinal  symptoms  are  pain, 
vomiting,  and  constipation.  The  pain  may  begin  suddenly, 
while  the  patient  is  in  apparently  good  health,  and  is  usually 
localized,  intermittent,  and  colicky.  It  soon  becomes  more 
intense  and  continuous,  and  spreads  ov^er  the  abdomen,  being, 


IN'J-JCST/NAL    OBSV'A'IJCT/ON.  485 

however,  more  severe  in  its  original  situation.  Tenesmus  oc- 
curs only  if  the  rectum  be  involved.  Vomiting  is  constant 
and  distressing.  The  vomited  matters  are  at  first  gastric,  then 
bilious,  and  finally  stercoraceous.  The  higher  up  the  ob.struc- 
tion  the  earlier  does  the  fecal  vomiting  occur;  but  true  fecal 
vomiting  cannot  occur  with  obstructions  above  the  upper 
third  of  the  ileum.  The  vomiting  may  cease  at  the  approach 
of  the  fatal  issue,  or  it  may  be  replaced  by  distressing  and 
obstinate  hiccough.  Constipation  is  usually  preceded  by  the 
emptying  of  the  intestine  below  the  seat  of  obstruction. 
There  is  also  an  absence  of  flatus.  In  intussusception  there 
may  be  discharges  of  mucus  and  blood.  If  the  obstruction 
be  low  down  in  the  intestinal  tract,  the  abdomen  is  greatly 
distended  and  active  peristalsis  is  visible,  but  if  the  obstruc- 
tion be  higher  up  these  symptoms  are  not  present.  At  first 
the  abdomen  is  insensitive;  later,  exquisite  tenderness  is 
developed.  The  face  becomes  pallid  and  anxious  ;  there  is 
incessant  thirst ;  the  pulse  is  feeble  and  either  rapid  or  slow; 
the  urine  is  diminished  or  suppressed.  There  is  not  apt  to 
be  fever ;  on  the  contrary,  the  temperature  may  be  subnor- 
mal. Symptoms  of  collapse  or  of  peritonitis  appear,  and 
the  patient  rarely  lives  beyond  the  fourth  or  the  sixth  day. 

Diagnosis. — The  determination  of  the  seat  of  the  lesion 
is  often  extremely  difficult.  If  the  obstruction  be  in  the 
duodenum  or  the  jejunum,  vomiting  occurs  early,  collapse 
is  rapid,  there  is  no  tympanites,  and  the  urine  is  usually 
suppressed.  If  the  lower  ileum  or  caecum  be  obstructed, 
the  abdomen  is  distended  in  the  umbilical  region,  the  flanks 
are  flattened,  and  active  peristalsis  can  be  seen.  If  the 
colon  or  the  rectum  be  occluded,  the  flanks  become  likewise 
distended,  there  may  be  tenesmus,  and  the  symptoms  are 
not  as  severe  as  in  the  preceding  forms.  If  four  quarts  of 
water  can  be  injected  slowly  so  as  to  fill  the  colon  and  the 
caecum,  the  obstruction  must  be  in  the  small  intestine. 

Diagnosis  of  the  Course  of  the  Obstruction. — Intiissiisception 
is  essentially  a  disease  of  children.  A  sausage-shaped 
tumor  usually  occurs  before  the  third  day  in  the  region  of 
the  ascending  or  transverse  colon.  There  is  usually  tenes- 
mus, with  the  passage  of  bloody  mucus.     Examination  by 


486        MAXUAL    OF   THE   PKACTICJ:    OF  MEDICINE. 

rectum  may  reveal  the  lesion.  Fecal  vomiting;  is  not  com- 
mon, and  abdominal  distention  occurs, in  t)nl\-  one-third  of 
the  cases. 

Strangulation  is  not  common  except  during  adult  life. 
There  is  usually  a  history  pointing  to  the  presence  of  peri- 
toneal adhesions.  Pain  is  excessive ;  vomiting  is  incessant 
and  soon  becomes  fecal ;  prostration  rapidl)'  becomes  ex- 
treme. There  is  absolute  constipation,  but  no  tenesmus, 
and  there  is  no  tumor  to  be  detected. 

Volvulus  is  diagnosed  with  great  difficulty,  although  it 
may  be  suspected  if  the  sigmoid  flexure  be  involved.  As 
twists  of  the  sigmoid  flexure  are  often  produced  b\'  the 
weight  of  accumulated  feces,  a  history  of  fecal  accumulation 
often  precedes  the  accident. 

Foreign  bodies  usually  lodge  at  the  ileo-ca^cal  valve. 
There  may  be  the  history  of  some  bulky  object  swallowed, 
or  of  the  passage  of  previous  gall-stones. 

For  the  diagnosis  o{  fecal  impaction  see  pp.  490,  491. 

The  diagnosis  should  also  be  made  from  functional 
obstruction  occurring  in  h\'sterical  patients,  and  usually 
following  blows  upon  the  abdomen,  peritonitis,  or  the 
reduction  of  a  hernia.  The  lesion  seems  to  be  a  tempo- 
rary cessation  of  peristaltic  movements,  as  the  result  of 
which  the  downward  advance  of  the  intestinal  contents  is 
checked.  In  every  case  external  strangulation  by  hernia 
must  be  excluded  by  careful  search.  Acute  hemorrhagic 
pancreatitis  may  so  closely  resemble  intestinal  obstruction 
that  a  differential  diagnosis  cannot  always  be  made. 

The  prognosis  of  every  case  of  obstruction  is  grave,  and 
usually  is  absolutely  unfavorable  unless  the  obstruction  be 
relieved  by  surgical  measures.  Spontaneous  cure  of  intus- 
susception has  been  mentioned,  but  few  children  live  long 
enough  for  the  result  to  take  place.  Spontaneous  cure  may 
result  in  exceptional  cases  of  strangulation  b\"  the  formation 
of  a  fistula  between  two  coils  of  intestine. 

Treatment  should  be  prompt  and  energetic.  Purgatives 
are  absolutely  contraindicated.  The  patient  should  be  put 
under  the  influence  of  opium  almost  to  the  point  of  semi- 
narcotization,  the  respirations   being  kept  between   10  and 


///CMC A' A' ///I  GE  FROM    'J'lIE    INTESTINE.  487 

14  by  its  repeated  administration.  By  this  treatment  all 
peristaltic  action  is  checked,  so  that  the  j^ut  will  have  a 
chaiice  to  untwist  or  to  free  itself  from  obstructing  bands  or 
from  its  invagination.  The  vomiting  and  pain  are  also 
checked,  and  the  danger  of  collapse  is  lessened. 

Washing  out  of  the  stomach  with  warm  water  may 
be  repeated  three  or  four  times  a  day.  In  some  cases 
this  treatment  has  been  useful  in  diminishing  peristalsis 
and  in  lessening  the  abdominal  pressure  above  the  ob- 
struction. The  colon  should  be  flooded  with  warm  water, 
the  patient  being  in  the  knee-chest  position  and  preferably 
under  the  influence  of  an  anaesthetic.  Inflation  of  air  may 
be  practised,  the  air  being  introduced  by  a  Davidson  syringe, 
or  the  rectal  tube  may  be  attached  to  a  siphon  of  carbonated 
water.  These  latter  methods  are  most  useful  in  cases  of 
intussusception,  but  they  are  not  devoid  of  danger,  as  rup- 
ture of  the  bowel  has  resulted  when  undue  force  has  been 
used.  Inflation  and  injection  of  water  are  of  no  service 
should  the  intussusception  last  longer  than  forty-eight 
hours,  as  by  that  time  inflammatory  fixation  will  have 
occurred. 

These  medicinal  measures  should  not  be  continued  after 
forty-eight  hours,  nor  in  any  case  in  which  the  symptoms 
are  rapidly  becoming  urgent,  but  laparotomy  should  be 
performed  at  once.  Laparotomy  should  be  done  as  early 
as  possible  in  cases  of  strangulation,  volvulus,  and  impaction 
of  foreign  bodies,  before  the  interference  with  the  circulation 
has  led  to  sloughing  of  the  intestinal  wall. 

HEMORRHAGE    FROM  THE    INTESTINE; 
ENTERORRHAGIA. 
Etiolog-y. — Hemorrhage  from  the  intestine  is  a  symptom 
that  may  be  produced  in  a  variet}'  of  ways  : 

1.  By  ulceration  of  the  intestines  of  any  form. 

2.  By  irritant  and  corrosive  drugs. 

3.  By  local  injuries,  such  as  those  inflicted  by  foreign 
bodies,  by  hardened  fecal  masses,  and  by  intestinal  parasites, 
especially  by  the  anchylostoma  duodenale  and  the  distomum 
haematobium. 


488        .U.IXC.IL    OF   THE   PKACT/CF.    OF  MEDICIXE. 

4.  By  active  congestion  in  severe  inflammations,  in  intus- 
susception and  volvulus,  and  following  the  reposition  o{  an 
incarcerated  hernia. 

5.  B}'  passive  congestion  with  disease  of  the  heart  and 
lungs,  with  obstruction  in  the  portal  circulation  and  with 
hemorrhoids  and  venous  varices. 

6.  By  diseases  of  the  blood-vessels,  especially  amyloid 
degeneration,  or  by  aneurysm  or  embolism  of  a  branch  of 
the  mesenteric  artery. 

7.  B\'  tumors  of  the  intestine,  especially  cancer  and  polypi. 

8.  By  causes  without  the  intestine,  as  when  blood  enters 
the  intestine  from  the  stomach  or  from  a  ruptured  aneurysm 
of  the  abdominal  aorta. 

9.  By  constitutional  diseases,  especially  pernicious  anae- 
mia, leukaemia,  pseudo-leukaemia,  scurvy,  purpura  haemor- 
rhagica,  septicaemia,  profound  jaundice,  yellow  fever,  acute 
yellow  atrophy  of  the  liver,  and  poisoning  b}'  phosphorus. 
Hemorrhage  may  also  occur  in  conditions  of  hunger  and 
inanition. 

10.  Hemorrhages  in  the  new-born  (melasna  neonatorum) 
may  be  due  to  acute  fatty  degeneration  or  to  s\'philitic 
degeneration  of  the  blood-vessels,  to  haemophilia,  or  to 
puerperal  infection. 

Symptoms. — The  blood  may  be  vomited  or  be  passed 
by  the  bowel,  or  the  patient  may  die  before  the  blood  ap- 
pears (concealed  hemorrhage).  Blood  from  the  rectum  or 
the  sigmoid  flexure  is  bright  red,  and  its  passage  is  accom- 
panied by  straining.  Blood  from  the  lower  bowel  is  also 
smeared  over  the  fecal  masses.  Blood  from  the  ileum  is 
usually  dark  red,  the  normal  color  generally  being  restored 
by  adding  water  to  the  stools,  and  its  passage  is  accompanied 
by  increased  peristalsis  and  diarrhoea.  Blood  from  the  jeju- 
num and  the  duodenum  is  dark  and  tarry  from  the  change 
of  the  haemoglobin  into  haematin.  These  dark  stools  may 
resemble  those  produced  by  eating  huckleberries  or  by 
taking  iron  or  bismuth,  but  the  differential  diagnosis  is  to 
be  made  positively  by  the  spectroscope  and  by  the  finding 
of  h^ematin-crystals  in  the  stools. 

The  general  symptoms  are  those  of  hemorrhage  in  gen- 


FECAL   ACCUMb'LAJ-fON.  489 

eral.  Following  the  hemorrhage  the  bowels  may  be  obsti- 
nately constipated  and  there  may  be  a  high  temperature 
(septic  fever  or  resorption-fever). 

Treatment. — Absolute  bodily  and  mental  rest  must  be 
enforced,  and  no  food  should  be  allowed  for  from  twenty- 
four  to  forty- eight  hours.  Opium  should  be  given  in  doses 
sufficient  to  check  peristalsis  ;  this  drug  is  also  of  service 
in  controlling  restlessness  and  collapse-symptoms.  Ice 
applied  to  the  abdomen,  so  often  recommended,  is  not  only 
useless  but  actually  harmful,  tending,  as  it  does,  to  stir  up 
peristaltic  action.  For  large  hemorrhages  astringent  drugs 
by  the  mouth  do  no  good,  but  in  repeated  small  hemorrhages 
ergotin,  turpentine,  erigeron,  hydrastis  canadensis,  acetate 
of  lead,  gallic  acid,  and  large  doses  of  bismuth  subnitrate 
are  of  great  service.  If  the  bleeding  come  from  the  rectum 
or  low  down  in  the  colon,  astringent  injections  may  be  em- 
ployed, but  they  should  not  be  resorted  to  as  a  routine 
measure,  because  of  their  tendency  to  quicken  peristalsis. 
Tamponage  of  the  rectum  causes  retention  of  gas,  straining 
efforts,  and  increased  intestinal  peristalsis,  and  it  should  not 
be  employed  except  in  cases  of  bleeding  from  the  lower 
portion  of  the  rectum. 

FECAL    ACCUMULATION. 

Etiology. — Fecal  accumulation  may  be  primary,  or  sec- 
ondary to  stricture  of  the  intestine.  In  the  primary  cases 
there  is  usually  the  history  of  previous  constipation,  although 
at  the  time  of  examination  the  bowels  may  be  loose.  In 
other  cases  the  accumulation  results  from  weakness  of  ex- 
pulsive efforts,  and  is  common  after  prolonged  illnesses,  as 
typhoid  fever. 

Patholog-y. — The  situation  of  the  impaction  is  usually  in 
the  caecum  or  in  the  rectum,  but  it  may  be  at  an\'  part  of 
the  large  intestine.  The  fecal  masses  may  totally  occlude 
the  lumen  of  the  gut,  or  they  may  be  packed  in  the  lateral 
pouches  of  the  colon,  leaving  a  passage  through  which  nor- 
mal stools  may  pass.  If  the  accumulation  be  large,  a  tumor 
will  be  formed,  which  may  give  rise  to  pressure-symptoms, 
especially  if  the  rectum  be  the  seat  of  the  impaction.     The 


490       u.i.vc.i/.  OF  riiE  practke  of  Mrnicfxii. 

lon^^er  the  fecal  masses  are  retained,  the  harder  they  become^ 
.so  that  they  may  even  resist  the  edije  of  a  knife.  The 
accumuhition  varies  in  amount,  in  extreme  cases  exceed- 
ing fifteen  or  twenty  pounds  in  weight. 

Symptoms. — Two  distinct  types  of  fecal  accumulation  are 
observed — a  complete  and  an  incomplete  form. 

COMPLKTE    FeCAI.    IMPACTION. {d)   If  the    fiCiKlll   be    the 

seat  of  impaction,  the  patient  will  suffer  from  the  effects  of 
constipation  and  will  complain  of  pain  and  tenderness  in  the 
c?ecal  region.  To  these  cases  the  term  "  stercoral  typhlitis  " 
is  often  applied.  Examination  will  reveal  the  presence  of  a 
tumor — not  soft,  baggy,  painless,  and  sausage-shaped,  as 
ordinarily  described,  but  hard,  irregular,  and  more  or  less 
tender,  so  closely  resembling  the  characteristics  of  a  morbid 
growth  that  a  diagnosis  is  impossible  by  examination  alone. 
At  some  particular  time  the  obstruction  becomes  complete. 
Constipation  is  absolute,  not  even  gas  being  passed  ;  the 
temperature  rises  to  from  ioi°  to  104°  F. ;  the  pul.se  is 
rapid  and  feeble.  The  abdomen  becomes  tender  and  tym- 
panitic, and  there  is  pain,  either  paroxysmal  and  colicky  or 
like  the  exquisite  pain  of  peritonitis.  Respirations  are  rapid 
and  thoracic.  The  case  closely  resembles  one  of  appen- 
dicitis with  general  peritonitis,  but  in  fecal  impaction  exam- 
ination reveals  a  greatly  increased  peristalsis  of  the  intestine, 
whereas  in  peritonitis  all  peristaltic  action  is  checked.  Un- 
less relieved,  gastric,  bilious,  and  stercoraceous  vomiting 
occurs;  the  patient  is  more  and  more  prostrated,  and  dies 
with  all  the  symptoms  of  intestinal   obstruction. 

The  prognosis  of  this  form  of  impaction  is  good  if  the  case 
be  properly  treated.  -  Relapses,  however,  are  likely  to  occur. 

Treatmoit. — In  this  form  of  impaction  purgatives  are 
absolutely  contraindicated.  as  by  the  violent  expulsive  efforts 
of  the  bowel  produced  by  their  action  the  hardened  mass  is 
jammed  more  tightly  into  the  distended  intestine.  Exactly 
the  opposite  treatment  is  indicated  :  opium  is  to  b^  given  in 
doses  sufficient  to  check  peristalsis  and  to  relax  the  intes- 
tinal .spasm  at  the  seat  of  the  impaction.  Under  this  treat- 
ment the  tumor  can  be  felt  to  move  along  the  colon  from 
day  to  day.     When  the  mass   reaches  the  transverse  colon. 


FI'ICAL    ACCUMIJJ.ATION.  49  I 

copious  salt-water  irrigations  will  bring  away  large  quan- 
tities of  hardened  feces.  When  the  impaction  is  once 
broken  up  opium  should  be  discontinued  and  the  use  of 
laxatives  should  be  begun,  the  best  of  these  being  castor  oil 
in  small  repeated  doses.  Faradism  and  massage  applied 
along  the  course  of  the  colon  are  often  of  service  in  pro- 
moting the  passage  of  the  fecal  masses.  To  prevent  reac- 
cumulation,  strjxhnine  must  be  given  for  months  to  coun- 
teract the  enfeeblement  of  the  intestinal  wall,  and  the  bowels 
should  be  kept  freely  open  by  appropriate  medication. 

[b)  If  the  rcctiiui  be  the  seat  of  the  impaction,  there  will 
result  ineffectual  attempts  at  defecation,  with  straining  and 
tenesmus,  so  that  fecal  impaction  should  be  suspected  in 
every  person,  especially  the  aged  and  those  who  are  con- 
valescing from  a  long,  weakening  illness,  in  whom  the 
symptoms  of  dysentery  appear.  Pressure  on  the  uterus 
may  cause  uterine  symptoms.  There  may  develop  neuralgia 
from  pressure  on  the  sacral  nerves,  seminal  emissions,  or 
nocturnal  enuresis. 

The  diagnosis  is  readily  made  by  rectal  examination, 
which  reveals  the  presence  of  hard  scybalae  in  the  rectum. 

Treatment  consist  in  breaking  the  impaction  mechan- 
ically and  in  removing  the  scybalae  by  the  fingers,  by  the 
handle  of  a  spoon,  or  by  repeated  enemata. 

Incomplete  Fecal  Impaction. — This  form  of  impaction 
is  usually  seen  in  elderly  persons  with  atony  of  the  colon. 
The  fecal  masses  are  packed  in  the  lateral  pouches  of  the 
colon,  leaving  a  passage  channelled  through  the  centre. 
The  prominent  symptom  is  diarrhcea,  the  loose  stools  aris- 
ing from  the  irritation  of  the  large  intestine  above  the  im- 
paction. Some  patients  become  poisoned  by  the  accumu- 
lation, run  down,  and  become  so  prostrated  that  the  case 
may  actually  resemble  typhoid  fever.  The  condition  is  to 
be  suspected  in  every  case  of  chronic  diarrhoea  in  old  people. 
Examination  may  reveal  scybalae  in  the  rectum,  or  there 
may  be  a  sense  of  resistance  with  some  dulness  over  the 
descending  colon. 

Treatnie7it  consists   of  purgation  and  colon-irrigation  to 


49-        .V.l.YC.lA    OF   THE   PRAC'IICE    OF  MF.DfCIXE. 

bring  away  the  fecal  masses.     Checking  the  diarrhcea  with 
astringents  regularly  aggravates  the  condition. 

AMYLOID    DEGENERATION    OF   THE   INTESTINE. 

Etiology. — Ani}loid  degeneration  of  the  intestine  occurs 
as  a  secondary  change  in  phthisis,  in  prolonged  suppura- 
tion, especially  of  the  bones,  and  in  constitutional  syphilis. 

Pathology. — The  lesion  involves  the  large  and  the  small 
intestine  and  is  especially  marked  in  the  lower  ileum.  The 
am\-loid  degeneration  begins  first  in  the  walls  of  the 
smaller  arteries,  and  in  advanced  cases  may  involve  the 
whole  thickness  of  the  intestinal  wall.  Ulceration  of  the 
mucous  membrane  is  not  unconmion. 

Symptoms. — The  principal  symptom  is  a  chronic  diar- 
rhoea without  fever  (unless  from  the  primary  disease),  pain, 
or  tenderness.  Blood  and  pus,  if  appearing  in  the  stools, 
are  indicative  of  ulcerations.  The  diagnosis  is  aided  by  the 
presence  of  the  causative  disease  and  by  the  finding  of  amy- 
loid changes  in  other  organs,  as  the  liver  and  the  spleen. 


4.  DISEASES  OF  THE  PERITONEUM. 

ACUTE   PERITONITIS. 
Etiology. — Peritonitis  may  be  primary  or  secondary. 

1.  Primary  or  idiopathic  peritonitis  is  exceed ingh'  rare. 
It  may  develop  after  exposure  to  wet  and  cold,  or  as  a 
terminal  event  in  Bright's  disease. 

2.  Sccojidary  peritonitis  follows  infection  from  inflamma- 
tion or  perforation  of  any  of  the  organs  covered  with  peri- 
toneum. It  thus  may  follow — {a)  Penetrating  wounds  and 
laparotomies.  (<^)  Rupture  or  perforation  of  any  of  the 
abdominal  viscera,  ic)  Rupture  of  an  abdominal  abscess, 
such  as  appendicitis  or  suppurating  inflammation  of  the 
Fallopian  tubes.  It  has  also  followed  rupture  of  an  appar- 
ently normal  Graafian  follicle  or  extra-uterine  gestation.  It 
has  also  occurred  after  perforation  of  the  diaphragm  in  em- 
pyema,    [d)  Extension  from  inflammation  or  ulceration  of 


ACU'J'J''.    J'J:lsfJ  ON/'J'/S.  493 

the  stomach  or  intestines,  cancer  or  suppurative  inflarnma- 
tions  of  the  spleen,  liver,  pancreas,  and  retroperitoneal  tis- 
sues, or  strangulated  hernia,  [e)  Pelvic  conditions — septic 
uterine  conditions,  decomposing  thrombi,  etc.  Infection 
may  be  carried,  as  in  the  case  of  gonorrhoea,  through  the 
Fallopian  tubes  without  the  tubes  being  involved. 

Bacteriolog-y. — The  bacterium  coli  commune  is  one  of 
the  most  frequent  micro-organisms  found  in  the  peritoneal 
exudate,  and  is  met  with  especially  in  peritonitis  due  to 
intestinal  perforation.  Next  in  frequency  are  the  pyogenic 
micrococci,  the  streptococcus  being  usually  associated  with 
puerperal  peritonitis,  while  the  staphylococcus  pyogenes 
aureus  or  albus  is  usually  found  in  cases  following  lapa- 
rotomy. The  diplococcus  pneumoniae  and  the  gonococcus 
have  been  found ;  the  amoeba  coli  may  occur  in  the  peri- 
tonitis accompanying  amoebic  dysentery. 

Varieties. — There  are  three  distinct  varieties  of  peritonitis: 
I.  Acute  peritoneal  -sepsis;  2.  Acute  diffuse  peritonitis;  3. 
Acute  circumscribed  peritonitis. 

Acute  Peritoneal  Sepsis. 

In  this  form  of  sepsis,  which  is  also  termed  "acute  peri- 
toneal septicaemia  "  and  "  perforative  peritonitis,"  we  have  a 
simultaneous  and  rapid  infection  of  the  whole  peritonea 
cavity  after  perforation  of  the  stomach  or  the  intestines, 
after  rupture  of  large  abscesses,  or  after  septic  penetrating 
wounds  or  laparotomies. 

Patholog-y. — The  peritoneum  may  appear  normal,  or 
may  be  injected  and  without  its  normal  lustre.  In  the  peri- 
toneal cavity  is  a  small  quantity  of  sticky,  non-purulent 
effusion,  consisting  chiefly  of  micro-organisms.  This  exu- 
date may  be  found  on  the  surfaces  of  the  peritoneum,  and 
cocci  may  be  found  in  the  lymph-spaces.  Feces,  contents 
of  the  stomach,  or  pus  from  a  ruptured  abscess  may  be 
present,  according  to  the  nature  of  the  primary  cause.  If 
the  patient  live  long  enough,  purulent  inflammation  follows 
and  the  lesions  of  acute  diffuse  peritonitis  are  found. 

The  symptoms  are  due  to  shock  and  to  toxaemia  from 
rapid  absorption  of  ptomaines.     There  is  usually  a  sudden 


494        MANUAL    OF   THE    PRACTfCE    OF  MEDICINE. 

sharp  pain  in  cases  of  rupture  or  perforation,  the  pain  ceas- 
ing as  the  patient  passes  into  the  condition  of  shock.  The 
pulse  becomes  rapid  and  feeble  ;  the  breathin<^"  is  rapid  and 
shallow;  the  skin  is  cold  and  clammy.  Slight  cyanosis 
appears,  and  the  patient  is  restless.  The  temperature  at  the 
onset  falls,  only  to  undergo  a  subsequent  rise  before  death 
to  105°  or  106°  F.  Death  from  tox?emia  results  in  from 
twelve  to  fifteen  hours  in  the  majority  of  cases.  In  cases 
of  milder  infection  the  patient  may  survive  long  enough  to 
develop  the  symptoms  of  diffuse  peritonitis. 

Acute  Diffuse  Peritonitis. 

This  form  of  sepsis,  which  is  also  termed  "  acute  general 
peritonitis,"  "purulent."  "progressive,"  "  progredient,"  or 
"exudative  peritonitis,"  occurs  when  a  general  infection  is 
not  severe  or  sudden  enough  to  cause  death  from  toxjemia, 
or  when  successive  areas  of  the  peritoneum  become  in  turn 
affected. 

Patholog-y. — The  intestines  are  inflated  with  gas  and  pro- 
trude through  the  post-mortem  incision.  The  peritoneum 
is  congested  or  pale  and  soggy  in  appearance,  and  is  covered 
with  fibrin  or  with  fibrin  and  pus  which  render  opposing 
peritoneal  surfaces  adherent.  There  is  an  exudation  of  serum 
in  cases  of  mild  infection,  or  of  pus  if  the  infection  be  more 
severe,  the  pus  being  thin  and  yellowish  or  thick  and  creamy 
or  putrid.  The  amount  of  the  exudate  varies  from  half  a 
liter  to  twenty  or  thirty  liters.  There  may  be  admixed 
contents  of  stomach  or  of  intestines  in  cases  of  perforation. 
Blood  is  not  found  except  after  penetrating  wounds  or 
laparotomies. 

If  the  patient  recover,  the  serum  is  absorbed,  the  fibrin 
and  pus  undergo  emulsification  and  absorption,  and  the 
exudate  becomes  organized,  so  that  the  peritoneum  becomes 
thickened  and  adherent.  These  connective-tissue  adhesions 
interfere  with  peristalsis  and  may  lead  to  internal  strangu- 
lation. 

Symptoms. —  Tympanites  is  usually  marked;  it  is  due  to 
the  paralytic  condition  of  the  intestine.  The  inflation  of  the 
intestines  may  be  so  marked  that  the  thoracic  viscera  are 


ACUTJ'.    J'/'lRI'JVNrJJS.  495 

displaced  upward,  interfering  with  the  breathing  and  the 
action  of  the  heart.  The  abdomen  in  these  cases  is  usually 
protuberant,  but  in  some  cases  it  is  of  natural  size,  although 
the  abdominal  wall  is  tense  and  hard.  In  other  abdominal 
diseases,  such  as  intestinal  obstruction,  tympanites  is  also 
present,  but  is  associated  with  active  peristalsis,  whereas  in 
peritonitis  the  association  of  tympanites  with  absence  of  peri- 
stalsis is  distinctive.  Over  the  distended  abdomen  a  tym- 
panitic note  is  obtained  by  percussion.  Tympany  over  the 
normal  liver-area  is  suggestive  of  gas  within  the  peritoneal 
cavity. 

Pain  and  tenderness  are  usually  at  first  limited  to  the  local- 
ity first  inflamed,  but  later  they  become  more  general.  The 
pain  is  very  severe,  with  acute  exacerbations.  The  patient 
lies  motionless  on  the  back,  with  the  knees  drawn  up  to 
relax  the  abdominal  wall,  and  the  breathing  is  rapid  and 
thoracic.  Restless  movements  of  the  arms  are  often  in 
sharp  contrast  to  the  immobility  of  the  body  and  the  lower 
extremities.  In  progressive  peritonitis  fresh  encapsulations 
of  pus  are  marked  by  an  extension  of  the  pain,  and  over 
these  freshly  involved  areas  the  note  is  dull  on  light  percus- 
sion. It  is  important  to  examine  the  patient  frequently  and 
to  remember  the  extent  and  location  of  these  areas  of  dul- 
ness.  In  rare  cases  it  is  possible  for  peritonitis  to  exist 
without  either  pain  or  tenderness. 

Vomiting  is  a  frequent  symptom.  In  some  cases  the 
vomiting  appears  to  be  due  to  irritability  of  the  stomach 
or  the  diaphragm,  and  is  accompanied  by  the  muscular 
efforts  of  vomiting.  The  vomited  matters  are  composed  of 
food  and  bile-stained  mucus.  In  other  cases  there  is  a  re- 
gurgitation of  gas  from  the  intestine  into  the  stomach,  so 
that,  without  muscular  effort,  the  gas  is  raised  with  a  brown- 
ish or  bilious  fluid.  In  other  cases,  as  death  approaches 
there  occurs,  without  effort,  a  regurgitation  of  a  brown  fluid 
which  may  possess  a  fecal  odor.  This  sign  is  of  serious 
import. 

Constipation  is  the  rule,  and  results  from  diminished  peri- 
stalsis. In  some  cases,  however,  diarrhoea  may  exist  from 
the  transudation  of  serum  into  the  cavitv  of  the  intestine. 


496        .U.t.Vr.lL    O/-'    THE    PRACTICE    OF  MEDICINE. 

This  diarrhcea  is  more  common  with  circumscribed  peri- 
tonitis, especially  if  it  has  lasted  for  some  time. 

The  tcjiipcraturc  is  usually  raised  and  runs  an  irregular 
course  bearing  no  direct  relation  to  the  severity  of  the  dis- 
ease. As  a  rule,  a  high  temperature  indicates  an  extensive 
peritonitis,  but  a  low  temperature  does  not  necessarily  in- 
dicate a  mild  attack.  The  fever  may  rise  to  102°  or 
104°  F.,  but  in  some  cases  there  occurs  a  sudden  fall  in  the 
temperature  with  the  appearance  of  collapse-symptoms,  indi- 
cating the  intervention  of  an  acute  peritoneal  sepsis.  Death 
soon  occurs  in  these  cases,  and  the  temperature  may  be 
high  again  at  the  time  of  the  fatal  issue.  A  steady  rise  in 
temperature  usually  indicates  a  spreading  peritonitis.  In 
some  cases  with  encapsulated  collections  of  pus  the  temper- 
ature may  become  markedly  remittent.  Absence  of  fever 
is  noted  as  a  rare  exception,  especially  in  peritonitis  of  such 
acuteness  and  intensity  that  the  symptoms  merge  into  those 
of  acute  peritoneal  sepsis. 

The  pulse  is  rapid  and  "  wiry,"  being  more  rapid  than  can 
be  accounted  for  by  the  fever.  As  a  rule,  the  pulse  gives 
reliable  information  as  to  the  general  condition  of  the 
patient. 

The  appearance  of  the  patient  is  characteristic.  The  face 
is  drawn  and  pinched  ;  the  nose  is  sharp  and  cold.  The 
tongue  has  a  tendency  to  become  brown  and  dry  even  if  the 
fever  be  moderate. 

The  intellect  remains  surprisingly  clear  even  to  the  last, 
but  there  may  appear  periods  of  muttering  delirium  asso- 
ciated with  the  symptoms  of  the  "  typhoid  state." 

The  duration  of  the  disease  is  usually  between  two  and 
seven  days. 

The  prognosis  is  exceedingly  grave.  Spreading  infection 
of  the  peritoneum  may  be  recovered  from  after  laparotomy 
and  drainage;  recovery  without  operation  may  follow  cases 
of  mild  infection  in  which  the  effusion  is  chiefly  fibrino- 
serous  without  much  pus  ;  but  in  all  cases  of  diffuse  peri- 
tonitis, however  mild  the  inflammation  may  appear,  a  most 
guarded  prognosis  must  be  given.  Cases  of  streptococcus 
infection    usuallv   die. 


ACUTE   J'ERlTONf'J'JS.  ^cjy 

Diagnosis. — The  following  conditions  are  most  apt  to  be 
mistaken  for  acute  peritonitis  : 

1.  Hysterical  peritonitis.  Here  every  symptom  of  peri- 
tonitis may  be  reproduced  exactly,  even  the  collapse,  the 
tympanites,  and  the  fever,  but  other  hysterical  manifesta- 
tions are  usually  present,  the  duration  of  the  attack  is  longer, 
and  there  may  be  recurrences. 

2.  Intestinal  obstruction.  Here  the  cause  is  usually  pres- 
ent (fecal  accumulation,  intussusception,  or  malignant 
growth),  the  temperature  is  not  usually  elevated,  the  vomit- 
ing is  often  stercoraceous,  and  intestinal  peristalsis  is  in- 
creased. 

3.  Acute  lieinorrJiagic  pancreatitis  may  exactly  simulate 
peritonitis,  so  that  a  diagnosis  between  the  two  conditions 
cannot  be  made. 

4.  Ruptured  tubal  pregnancy  gives  a  previous  history  of 
cramp-like  pains  and  cessation  of  menstruation. 

5 .  Rupture  of  an  abdominal  aneurysm  usually  gives  rise  to 
rapid  collapse  and  intense  anaemic  symptoms. 

Acute  Circumscribed  Peritonitis. 

Etiology  and  Pathology. — Acute  circumscribed  peri- 
tonitis, which  occurs  in  cases  in  which  adhesions  are  suffi- 
ciently resistant  to  limit  the  infection,  is  more  apt  to  occur 
with  infection  in  the  lower  abdominal  zone.  The  most 
frequent  cases  occur  from  inflammation  of  the  appendix  or 
from  puerperal  or  gonorrhoeal  infection  of  the  uterus  and 
the  Fallopian  tubes.  The  rupture  of  an  ulcer  of  the  stomach 
may  lead  to  a  circumscribed  peritonitis  within  the  lesser 
peritoneal  cavity.  There  may  thus  form  beneath  the  dia- 
phragm a  large  air-containing  abscess  to  which  the  name 
"  subphrenic  pyo-pneumothorax  "  has  been  applied.  If  the 
localized  abscess  be  small,  the  pus  may  eventually  be  ab- 
sorbed, encapsulated,  or  calcified  ;  extensive  collections  may 
burrow  or  perforate.  Gradual  infection  of  the  peritoneal 
cavity  results  in  progressive  peritonitis,  and  acute  peritoneal 
sepsis  may  result  from  the  internal  rupture  of  the  abscess. 

Symptoms  are  local  and  general.  Local  symptoms  con- 
sist of  pain,  tenderness,  and  the  presence  of  an  inflamma- 

.32 


498        MAXi'AL    OF   THE   PRACTICE    OF  MEDICIXE. 

tory  tumor.  General  symptoiiis  at  first  are  those  of  an  in- 
flammatory character — prostration  and  continuous  fever. 
Later  appear  the  septic  symptoms  of  pus-absor})tion,  irregu- 
lar fever,  chills,  cold  sweatings,  diarrhoea,  emaciation,  and 
delirium  at  night.  Ultimately  septicii^mia  develops,  with 
the  s)'mptoms  of  the  t\'[3hoid  condition. 

The  s\'mptoms  of  the  disease  may  at  any  time  merge  into 
those  of  acute  peritoneal  sepsis  or  of  progressive  peritonitis. 

Treatment  of  Peritonitis. 

Peritoneal  Sepsis. — The  treatment  is  that  of  surgical  shock 
— by  stimulation,  external  application  of  heat,  and  small 
doses  of  opium.  If  the  patient's  condition  justifies  the  risk, 
laparotom}'  may  be  performed,  perforations  closed,  and  the 
peritoneal  cavity  cleansed  with  warm  sterilized  boric-acid 
solution. 

Diffused  Peritonitis. — Mild  cases  may  be  treated  medicin- 
ally at  the  start,  but  it  is  advisable  for  a  surgeon  to  be  in 
constant  consultation  in  the  case,  so  as  to  be  ready  for  sur- 
gical interference  should  the  medical  treatment  be  unsuc- 
cessful. The  object  of  the  medical  treatment  is  to  prevent 
intestinal  peristalsis,  so  as  to  allow  of  the  formation  of  adhe- 
sions to  limit  the  infection.  The  drug  par  excellence  is 
opium,  and  the  amount  in  which  it  can  be  given  is  remark- 
able, as  in  peritonitis  there  exists  a  tolerance  of  the  drug. 
Alonzo  Clark's  method  was  to  give  such  doses  as  would 
keep  the  patient  semi-narcotized,  repeated  doses  being  given 
as  soon  as  the  respirations  exceeded  twelve  to  the  minute. 
In  ordinary  cases  from  4  to  8  grains  daily  sufficed,  but  as 
much  as  420  grains  have  been  given  in  a  single  day.  It  is 
said,  however,  that  the  same  tolerance  does  not  exist  for 
hypodermic  doses  of  morphine  as  when  the  drug  is  given  by 
the  mouth.  It  is  not  now  considered  necessary  to  employ 
such  heroic  doses,  but  only  as  much  morphine  is  given  as 
will  suffice  to  keep  the  patient  free  from  pain.  Larger  doses 
than  ^  grain  every  two  or  three  hours  are  rarely  required. 
Morphine  even  in  these  doses  should  always  be  given 
hypodermically. 


CHRONIC  j'KRrroNiT/s.  499 

Concentrated  saline  laxatives,  however,  may  be  given  at 
the  onset  in  cases  following  operations  or  septic  conditions. 

Local  applications  are  often  of  great  comfort  and  of  un- 
questionable utility.  For  the  earlier  stages  cold  ice-bags 
or  the  cold  Leiter  coil  is  serviceable,  but  after  five  or  six 
days  hot  applications  seem  to  be  preferable.  The  tym- 
panites may  be  relieved  by  turpentine  stupes  or  by  the 
passage  of  a  rectal  tube.  Lavage  of  the  stomach  may  re- 
lieve the  distention  of  the  upper  portion  of  the  abdomen. 
Fitz  recommends  the  frequent  puncture  of  the  distended 
bowel  with  a  small  hollow  needle  in  extreme  cases  of  me- 
teorism,  stating  that  the  danger  of  extravasation  or  of  the 
escape  of  gas  into  the  peritoneal  cavity  is  comparatively  slight. 

The  use  of  saline  purgatives  has  been  recommended  by 
Lawson  Tait  and  decried  by  others.  Certainly  it  would 
seem  that  the  increased  peristalsis  would  rupture  fine  lim- 
ited adhesions,  and  the  general  use  of  laxatives  is  to  be 
deplored.  No  harm  results  from  constipation  in  peritoneal 
cases.  Rectal  injections  may,  however,  be  given  to  relieve 
the  large  intestine.  In  all  cases  of  spreading  peritonitis 
with  urgent  symptoms,  surgical  treatment  is  the  only  one 
that  affords  the  patient  any  hope.  There  is  more  danger 
in  waiting  too  long  for  operative  interference  than  there 
is  in  operating  too  early  in  the  disease,  when  surgical  treat- 
ment may  not  be  necessary. 

Acute  cirainiscribcd  peritonitis  calls  for  surgical  treat- 
ment to  open  and  drain  the  abscess.  The  operation  may 
be  deferred  in  many  cases  until  the  limiting  adhesions  have 
had  time  to  become  firm. 


CHRONIC  PERITONITIS. 
Etiology. — Chronic  non-tubercular  peritonitis  may  suc- 
ceed an  acute  attack  or  may  be  chronic  from  the  first.  The 
most  frequent  cause  appears  to  be  repeated  tappings  for  the 
removal  of  ascitic  fluid  ;  but  the  condition  may  occur  with 
chronic  diffuse  nephritis  or  with  long-continued  abdominal 
or  pelvic  abscesses.  The  disease  is  more  common  in  alco- 
holic patients.       In   some   cases   no   definite  cause  can  be 


500        .UAXi:i/.    OF   77 IE   PRACTICE    OF  MEDICIXE. 

assigned,  but  many  of  the  so-called  "  idiopathic  "  cases  ulti- 
mately are  proven  to  be  tubercular. 

Pathology. — The  peritoneum  is  thickened  by  connective 
tissue,  and  opposing  surfaces  are  matted  and  massed  to- 
gether by  firm,  thick  adhesions.  In  extreme  cases  the  peri- 
toneum is  between  one-fourth  and  one-half  inch  in  thickness. 
In  places  there  are  congested  patches  cov^ered  with  recent 
deposits  of  fibrin.  The  omentum,  which  is  usually  much 
thickened,  is  rolled  up  to  form  a  sausage-shaped  tumor 
lying  tran.sversely  across  the  abdomen.  The  capsule  of  the 
liver  or  of  the  spleen  may  be  thickened,  contracted,  and  the 
volume  of  these  organs  correspondingly  reduced.  The 
mesentery  is  thickened  and  contracted.  There  may  be  but 
little  serum,  so  that  the  process  is  described  as  "  adhesive  " 
or  "proliferative  peritonitis,"  but  in  other  cases  ("ascitic  peri- 
tonitis ")  there  is  a  quantity  of  liquid  exudation,  either  free  or 
encapsulated  by  adhesions.  The  ascitic  form  seems  to  be  espe- 
cially common  in  children.  Chronic  peritonitis  may  be  dif- 
fused, or  the  process  may  be  limited  to  a  circumscribed  area. 

Symptoms  are  general  and  local. 

General  Syuiptoms. — There  is  a  progressive  loss  of  flesh 
and  of  strength  by  which  the  patient  becomes  finally  re- 
duced to  semi-invalidism.  The  temperature  may  at  times 
be  slightly  elevated. 

Local  Symptoms. — Pain  in  the  abdomen  is  constant  and 
annoying  rather  than  actually  severe.  There  is  usually 
considerable  tenderness  on  palpation.  Disturbances  in 
digestion  are  almost  constant.  The  bowels  are  usually  con- 
stipated, although  periods  of  diarrhoea  may  occur  from  time 
to  time.  Distortions  and  flexions  of  the  intestines  may  re- 
sult in  obstruction,  or  the  common  duct  may  be  so  twisted 
or  compressed  as  to  cause  persistent  jaundice.  Acute  ex- 
acerbations of  the  inflammation  may  occur,  with  moderate 
fever  and  a  marked  increase  of  the  pain  and  tenderness. 

In  children  between  two  and  ten  years  of  age  a  chronic 
peritonitis  which  cannot  be  traced  to  any  cause  is  not  un- 
common. The  ascites  is  considerable,  but  the  symptoms 
are  not  extreme  and  recovery  usually  ensues. 

The  results  of  a  physical  examination  are  not  always  uni- 


C//KON/C   IIJiMONRIIAG/C   PPIK I'rONITJS.  501 

form,  and  depend  upon  the  amount  of  the  thickening  and 
adhesions,  the  rolHng  up  of  the  omentum,  and  the  presence 
or  absence  of  a  serous  exudate.  If  there  be  much  thicken- 
ing with  matting  together  of  the  adhesions,  the  abdomen 
yields  a  doughy  resistance  to  palpation,  totally  unlike  the 
soft  feeling  of  a  normal  abdomen.  The  whole  abdomen 
may  even  appear  to  be  filled  with  a  resistant  nodular 
tumor.  If  the  omentum  be  rolled  up,  it  may  be  felt  as  an 
irregular  mass  lying  across  the  abdomen,  and  may  be  mis- 
taken for  the  nodular  edge  of  an  enlarged  liver.  If  there 
be  free  effusion,  the  abdomen  will  be  distended,  and  dulness 
or  flatness  will  be  obtained  over  the  dependent  portions  of 
the  abdomen,  as  well  as  over  the  flanks  in  the  dorsal  decu- 
bitus, with  a  tympanitic  note  over  the  uppermost  portions. 
By  changing  the  position  of  the  patient  there  is  a  relative, 
change  in  the  position  of  the  percussion-notes.  Fluctuation 
can  readily  be  appreciated.  Small  encapsulated  collections 
of  fluid,  surrounded  by  thickened  and  adherent  intestines, 
may  so  closely  resemble  tumors  that  a  differential  diagnosis 
from  cancerous  peritonitis  is  not  always  possible. 

The  duration  of  the  disease  is  months  or  years. 

For  the  diagnosis  from  tubercular  and  cancerous  peri- 
tonitis, see  the  articles  treating  of  these  diseases. 

The  prognosis  is  bad,  the  patients  usually  dying  ema- 
ciated ;  but  in  some  cases  the  disease  may  cease  progress- 
ing, or  recovery  may  follow  operative  treatment. 

Treatment  is  properly  surgical.  Ascitic  accumulations 
should  be  withdrawn  by  puncture  of  the  abdominal  wall. 
Laparotomy,  with  the  breaking  down  of  adhesions  and  the 
drainage  of  encapsulated  serous  effusions,  is  often  of  cura- 
tive value.  Medicinal  treatment  is  symptomatic.  It  is 
claimed  that  benefit  is  derived  from  abdominal  inunctions 
of  mercurial  ointment. 

CHRONIC   HEMORRHAGIC   PERITONITIS. 
This    rare    condition    is    analogous    to    chronic    internal 
pachymeningitis.      The  peritoneum  is  thickened  by  con- 
nective tissue,  and  on  its  free  surface  are  wide,  thin-walled 
blood-vessels.       By   successive    hemorrhages  fibrin    is   de- 


502      M.i.yr.iL  or  the  pa'.ict/ce  of  medicine. 

posited  in  layers,  so  that  the  thickening  is  increased.  The 
process,  which  is  usually  circumscribed,  is  most  frequent  in 
the  pelvic  region. 

TUBERCULAR   INFLAMMATIONS    OP    THE 
PERITONEUM. 

The  following  forms  of  tubercular  inflammations  of  the 
peritoneum  are  described:  i.  Acute  tuberculosis  of  the 
peritoneum;  2.  Acute  tubercular  peritonitis;  3.  Chronic 
tubercular   peritonitis. 

Acute  Tuberculosis  of  the  Peritoneum. 

In  this  form  of  inflammation  the  peritoneum  is  studded 
with  tubercles  as  one  of  the  lesions  of  acute  miliary  tuber- 
culosis. The  peritoneum  is  otherwise  normal,  and  shows 
no  coincident  inflammatory  change,  although  there  may  be 
an  effusion  of  clear  serum. 

The  clinical  symptoms  are  latent  or  obscure.  Pain  and 
tenderness  are  rarely  observed.  The  abdomen  may  be 
distended  and  may  present  the  evidences  of  a  peritoneal 
effusion. 

Acute  Tubercular  Peritonitis. 

Etiology. — This  condition  is  seldom  primary,  but  ex- 
tension of  the  disease  to  the  peritoneum  usually  takes  place 
from  the  intestines,  the  lungs,  the  pleura,  the  mesenteric 
glands,  the  Fallopian  tubes,  or  the  genito-urinary  tract  in 
either  sex. 

Pathology. — There  is  a  miliary  tuberculosis  accompanied 
by  the  ordinary  products  of  inflammation.  The  peritoneum 
is  studded  with  tubercular  granules  or  plates.  Elsewhere 
the  membrane  is  congested  and  coated  with  fibrin  or  with 
fibrin  and  pus.  There  is  usually  an  abundant  effusion  of 
either  clear  or  turbid  serum,  occasionally  hemorrhagic, 
rarely  purulent. 

The  symptoms  usually  begin  abruptly.  There  are  more 
or  less  severe  abdominal  pain  and  tenderness,  with  the  other 
local  symptoms  of  a  general  peritonitis.  The  temperature 
runs  an  irregular  course  varying  between  iOi°  and  105*^  F., 


TUBERCULAR    RJ'.R rrONf'JfS.  503 

and  is  usually  higher  at  night,  although  there  has  been  ob- 
served an  "  inverse  "  temperature  with  evening  remissions. 
The  pulse  becomes  increasingly  rapid  and  feeble.  There  is 
a  progressive  loss  of  flesh  and  of  strength.  There  may  be 
diarrhoea  or  constipation,  or  these  conditions  may  alternate 
with  each  other.  The  "  typhoid  condition "  ultimately 
develops. 

Physical  Examination. — The  abdomen  is  distended  and 
tympanitic.  Fluctuation  is  detected  in  one-third  of  the 
cases,  especially  in  the  earlier  stages  of  the  disease.  Irreg- 
ular masses  may  be  detected  on  palpation  in  protracted 
cases  ;  these  masses  may  be  due  (i)  to  a  thickened  and 
rolled-up  omentum,  (2)  to  encapsulated  exudation,  (3)  to 
tubercular  mesenteric  glands,  or  (4)  to  retracted  and  thick- 
ened intestinal  coils. 

Diagnosis. — The  symptoms  are  not  equally  prominent  in 
all  cases,  but  there  is  considerable  variety  in  their  relative  pre- 
ponderance. If  the  general  outweigh  the  local  symptoms, 
the  case  may  closely  resemble  one  of  typhoid  fever.  The 
diagnosis  may  be  rendered  even  more  definite  by  a  rose- 
colored  eruption  over  the  abdomen,  resembling  typhoid  spots, 
which  occasionally  appears  in  tubercular  peritonitis.  If  the 
local  symptoms  are  the  more  prominent,  the  case  may  be 
regarded  as  one  of  non-tubercular  peritonitis ;  but  the  diag- 
nosis is  to  be  made  from  the  latter  condition  by  the  absence 
of  a  cause  for  non-tubercular  infection,  by  the  presence  of 
tubercular  disease  elsewhere,  especially  in  the  organs  enu- 
merated under  the  heading  of  Etiology^  and  by  the  more 
protracted  course  of  the  disease. 

The  duration  of  the  disease  is  from  four  to  six  weeks. 

The  prognosis  is  exceedingly  bad,  but  is  not  absolutely 
hopeless. 

Treatment  should  be  surgical.  The  abdomen  should  be 
opened  and  drained.  Operative  treatment  is  more  effectual 
in  chronic  cases,  but  in  a  few  acute  cases  cure  has  resulted 
from  such  peritoneal  drainage.  Medical  treatment  is  en- 
tirely symptomatic. 


504     j/.i.vr.l/.  of  t/if.  practjcr  of  medicixe. 

Chronic  Tubercular  Peritonitis. 
Etiology. — The  etiology  of  tlie  chronic   is  the  same  as 
that  of  the  acute  form  of  tubercular  peritonitis. 
Pathology. — Two  types  are  recognized  : 

1.  Ti(bcn'ular  Ascites. — The  peritoneum  is  thickened  and 
is  studded  with  fibrous  or  cheesy  tubercles  in  granules  or 
in  larger  masses.  The  omentum  is  thickened  and  rolled  up; 
the  mesenter\'  is  retracted.  There  are  but  icw  adhesions. 
There  is,  however,  an  abundant  serous  effusion,  giving  rise 
to  the  symptoms  and  physical  signs  of  ascites.  The  effu- 
sion is  usually  serous,  but  in  rare  instances  it  may  be  hem- 
orrhagic or  milky. 

2.  Tubercular  Peritonitis  with  AdJiesious. — All  the  viscera 
are  matted  together  in  one  boggy  mass,  either  by  connective- 
tissue  thickening  and  adhesions  or  by  soft  gelatinous  fibrin. 
Fluid  effusion  is  usually  scanty  and  may  be  encapsulated. 
The  retraction  of  the  omentum  and  the  mesentery  is  the 
same  as  in  chronic  non-tubercular  peritonitis.  Throughout 
the  thickened  peritoneum  are  old  tubercles  and  cheesy 
masses.  Fibroid  transformation  of  tubercle  is  more  com- 
mon in  the  peritoneum  than  in  any  other  locality  of  the 
body. 

The  symptoms  of  the  tubercular  resemble  those  of  the 
non-tubercular  form.  There  are,  however,  tubercular  lesions 
elsewhere  that  modify  the  clinical  picture  of  the  disease, 
and  the  course  of  the  tubercular  form  is  more  severe  and 
uncompromising  than  that  of  the  non-tubercular  form. 
Some  cases  run  a  latent  or  an  insidious  course,  and  are  acci- 
dentally discovered  at  a  laparotomy  or  at  the  post-mortem 
table.  In  these  cases  the  peritonitis  is  more  apt  to  be  cir- 
cumscribed, and  usually  it  is  found  in  the  pelvis,  from  infec- 
tion through  the  Fallopian  tubes. 

Malignant  disease  of  the  peritoneum,  as  a  rule,  progresses 
more  rapidly  than  tubercular  peritonitis,  and  is  secondary 
to  malignant  disease  of  some  one  of  the  abdominal  organs 
that  can  readily  be  diagnosed. 

The  prognosis  is  grave,  but  is  not  so  hopeless  as  might 
be  expected.  The  brilliant  results  following  laparotomy 
and  drainage  have  made  a  favorable  prognosis  the  rule. 


CANCl'.R    01'    'J'l/I':    I'KRJ'J'VNI'JJM.  505 

Treatment. — It  is  claimed  that  from  70  to  80  per  cent, 
of  the  cases  operated  on  have  been  cured,  but  evidence  is 
wanting  that  even  the  majority  of  these  cases  were  actually- 
tubercular.  In  some  cases  merely  an  exploratory  laparotomy 
in  which  the  abdomen  has  been  opened,  inspected,  and 
sewed  up  again  at  once  has  been  productive  of  good  results. 

The  medicinal  treatment  is  essentially  constitutional  and 
symptomatic. 

CANCER    OP    THE    PERITONEUM. 

Etiolog-y. — Primary  cancer  of  the  peritoneum  is  exceed- 
ingly rare,  although  cases  of  primary  colloid  growths  of 
large  size  have  been  described.  Secondary  growths  occur 
in  connection  with  malignant  disease  of  any  of  the  abdomi- 
nal viscera.  The  disease,  which  is  more  common  in  women 
than  in  men,  occurs  during  advanced  life. 

Pathology. — The  peritoneum  is  studded  with  carcino- 
matous nodules  of  various  sizes,  the  favorite  seats  for  the 
deposits  being  the  omentum  and  the  mesentery,  the  perito- 
neum near  the  umbilicus,  and  Douglas's  fossa.  The 
nodules  may  be  small  and  discrete  or  larger  and  confluent, 
so  that  tumors  of  considerable  size  may  form.  Unaccom- 
panied by  coincident  peritonitis,  the  process  is  spoken  of  as 
"  carcinosis."  Usually,  however,  the  peritoneum  is  the  seat 
of  a  chronic  inflammation ;  it  is  thickened,  the  omentum  is 
rolled  up,  and  the  peritoneal  cavity  contains  an  effusion 
which  may  be  serous,  hemorrhagic,  or  milky  from  the  fatty 
degeneration  of  the  cancer-elements.  In  rare  cases  the 
effusion  may  become  purulent.  To  this  form  of  malignant 
deposits  with  associated  inflammation  the  term  "  cancerous 
peritonitis  "  is  given.  The  retroperitoneal  and  mesenteric 
glands  are  usually  involved,  and  the  inguinal  glands  may  be 
enlarged.  Perforation  or  fistulse  may  result  from  the  ulcera- 
tion of  the  cancer-masses,  and  fatal  hemorrhage  may  occur 
from  ulceration  within  the  bowel. 

Colloid  carcinoma  involves  the  peritoneum  diffusely, 
converting  it  to  a  thick,  gelatinous  mass,  often  of  enormous 
size. 

Symptoms. — i.  There  are  s}^mptoms  due  to  the  primary 


5o6      m.i\l:il  of  the  practice  of  medicjxe. 

growth.     Cachexia  is  usually'  evident  before  the  peritoneum 
becomes  involved. 

2.  Symptoms  of  chronic  peritonitis  are  present.  In 
many  cases  ascites  and  progressive  emaciation  are  the  prin- 
cipal complaints.  Fever  is  usualh'  present,  but  its  course  is 
similar  to  tliat  of  tubercular  peritonitis.  Pain  and  tender- 
ness are  usually  more  marked  than  with  ordinary  chronic 
peritonitis,  but  in  rare  instances  the  course  of  the  disease 
is  painless  throughout. 

3.  Severe  hemorrhages  may  result  from  ulcerations  with- 
in the  intestinal  walls,  or  rapidly  spreading  peritonitis  from 
perforation  may  develop.  Cachexia,  waxy  pallor,  and 
weakness  increase  with  the  progress  of  the  disease. 

Physical  examination  yields  no  distinctive  signs  by 
which  a  positive  diagnosis  may  be  made.  If  there  be  much 
effusion,  the  tumors  may  be  so  obscured  that  a  diagnosis 
from  chronic  peritonitis  is  impossible.  Usually^,  after  tap- 
ping, multiple  nodules  may  be  felt,  but  these  nodules  may  be 
mistaken  for  the  encapsulated  exudate  of  a  chronic  tubercu- 
lar peritonitis.  According  to  Osier,  multiple  nodules,  if 
large,  indicate  cancer,  particularly  in  persons  above  middle 
life,  whereas  nodular  tubercular  peritonitis  is  more  common 
in  children.  The  rolled-up  omentum  may  be  appreciated  as 
an  irregular  mass  lying  across  the  upper  abdominal  zone ;  it 
has,  however,  no  diagnostic  value,  as  the  same  condition 
occurs  in  chronic  tubercular  or  non-tubercular  peritonitis. 
Examination  by  the  rectum  or  the  vagina  should  be  resorted 
to  in  doubtful  cases,  as  Douglas's  fossa  is  frequently  in- 
volved early  in  the  course  of  the  disease.  Secondary 
nodules  about  the  navel  are  highly  suggestive  of  cancer. 

The  diagnosis  will  be  confirmed  if  cancerous  fras^ments 
be  removed  through  the  trocar  at  the  time  of  tapping. 
A  milky  appearance  of  the  fluid  is  suggestive,  but  is  not 
absolutely  diagnostic. 

The  further  diagnosis  from  tubercular  peritonitis  has 
been  spoken  of  under  the  latter  disease. 

If  the  growth  be  colloid,  the  results  of  physical  examina- 
tion are  altogether  different.  There  are  no  nodules  and  no 
ascites.        The   abdomen   is   symmetrically  enlarged,  often 


ASCITES.  507 

reaching  enormous  proportions.  On  palpation  the  abdomen 
is  apparently  filled  with  a  semi-solid  mass. 

The  prog-nosis  is  absolutely  bad.  As  cancerous  peri- 
tonitis usually  complicates  pre-existing  visceral  cancer,  the 
duration  of  the  disease  is  seldom  more  than  a  few  months. 
Cases  of  primary  growth  run  a  longer  course. 

Treatment  is  entirely  symptomatic.  The  fluid  may  be 
relieved  by  tapping  if  it  produce  discomfort,  but  the  ascites 
rapidly  returns.  Opium  should  be  given  in  doses  sufficient 
to  quiet  pain. 

ASCITES;  HYDROPERITONEUM ;  ABDOMINAL 
DROPSY. 

Etiology. — A  serous  exudate  within  the  peritoneal  cavity 
is  common  in  all  forms  of  chronic  peritonitis,  whether 
simple,  tubercular,  or  cancerous.  The  term  "  ascites,"  how- 
ever, should  more  properly  be  limited  to  a  serous  transuda- 
tion from  stasis,  without  inflammatory  changes.  The 
ascites  may  thus  be  due — {a)  to  obstruction  of  the  portal 
vein,  either  in  the  terminal  branches  within  the  liver,  as  in 
cirrhosis  of  the  liver,  or  in  a  larger  trunk  without  the  liver 
as  from  thrombus-formation,  from  external  pressure  by  pro- 
liferative peritonitis,  new  growths,  or  abdominal  aneur- 
ysms ;  (/;)  to  general  venous  congestion  arising  in  the  course 
of  chronic  heart  disease,  emphysema,  or  interstitial  pneu- 
monia; (r)  to  hydraemic  blood-conditions,  as  in  Bright's 
disease  or  in  advanced  ansemia. 

The  ascitic  fluid  is  pale  yellow,  with  occasionally  a  green- 
ish tinge,  and  is  usually  clear.  The  specific  gravity  varies 
between  loio  and  1015,  although  in  cases  due  to  cancer  of 
the  liver  the  gravity  may  be  as  high  as  1023.  The  fluid 
contains  albumin,  has  the  chemical  characteristics  of  blood- 
serum,  and  may  form  a  delicate  fibrinous  clot  on  standing. 
Ascitic  fluid  may  at  times  present  a  milky  appearance.  If 
this  appearance  be  due  to  the  admixture  of  chyle  (''  chylous 
ascites  "),  the  fat  is  molecular ;  if  due  to  layers  of  fat-globules, 
the  name  "  adipose  ascites  "  is  often  applied  to  the  fluid. 

Chylous  ascites  is  due  to  injury  to  the  thoracic  duct  by 
perforation,  rupture,  or  by  the  filaria  sanguinis  hominis,  or 


5o8        M.lXf.lL    OF   THE   PRACTICE    OF  MEDICIXE. 

to  its  thrombosis  or  obliteration.  In  adipose  ascites  the  fat 
originates  from  the  fatty  degeneration  of  cells,  usually  the 
product  of.  a  cancerous  or  tubercular  peritonitis. 

The  symptoms  of  ascites  are  due  to  the  mechanical 
weight  and  pressure  of  the  transudation. 

In  ascites  due  to  portal  obstruction  the  fluid  accumulates 
within  the  peritoneal  caxity,  sinking  into  the  most  depend- 
ent portions,  while  the  abdominal  organs  that  contain  air 
float  upon  the  fluid  as  far  as  their  peritoneal  attachment  will 
allow.  The  fluid  is  freely  mo\'able,  occupying  the  most 
dependent  portions  of  the  abdomen  with  every  change  of 
position.  If  the  fluid  does  not  thus  move  freel)-,  but 
changes  its  position  slowly  and  incompletely  or  remains 
immovable,  inflammatory  exudation  is  indicated.  Pressure 
upon  the  iliac  veins  will  cause  secondary  oedema  of  the 
lower  extremities.  In  ascites  due  to  diseases  of  the  heart 
and  the  lungs  or  to  hydrjtmic  blood-conditions  the  abdom- 
inal effusion  is  but  an  added  symptom  of  a  general  dropsi- 
cal condition,  and  is  associated  with  oedema  of  the  lower 
extremities,  and  usually  with  h}'drothorax. 

Physical  Signs. — In  the  dorsal  position  the  abdomen  is 
flattened  in  the  umbilical  region  and  bulges  in  the  flanks. 
In  the  upright  position  the  lower  abdominal  region  is  alone 
prominent.  In  extreme  distention  the  whole  belly  is 
rounded  and  the  skin  of  the  abdominal  wall  is  tense,  shin- 
ing, and  may  present  pinkish  striae  as  in  pregnancy.  The 
navel  is  usually  protuberant.  Enlarged  anastomosing  veins 
are  usually  seen  coursing  over  the  abdominal  wall. 

Percussion  gives  dulness  over  the  fluid  and  tympany 
over  the  overlying  intestines.  By  changing  the  position  of 
the  patient  the  relative  areas  of  these  percussion-notes 
becomes  correspondingly  altered.  Percussion  is  important 
in' differentiating  between  the  distention  of  ascites  and  that 
of  extreme  meteorism.  In  cases  of  moderate  effusion  dul- 
ness appears  in  the  umbilical  region  when  the  patient 
assumes  the   knee-chest  position. 

Fluctuation  is  obtained  by  the  transmission  of  a  wave 
from  one  side  of  the  abdomen  to  the  other  by  one  hand 
being  placed  over  one  flank  while  the  other  flank  is  lightly 


ASCITES.  509 

tapped.  In  this  way  even  a  small  amount  of  fluid  maybe 
detected  with  great  accuracy.  The  sign,  however,  may  fail 
when  there  is  great  effusion  under  high  pressure.  In  fat 
subjects  a  fluctuation-wave  may  run  across  the  lax,  flabby 
abdominal  wall,  but  this  superficial  wave  may  be  checked  by 
pressing  the  ulnar  edge  of  the  hand  firmly  upon  the  linea 
alba. 

The  prognosis  of  ascites  is  dependent  upon  its  cause. 

The  treatnaent  is  that  of  the  primary  cause.  Stimulants 
should  be  given  to  sustain  a  failing  circulation.  Anaemic 
conditions  require  appropriate  treatment.  The  fluid  may  be 
diminished  by  the  free  use  of  diuretics  and  cathartics, 
should  the  patient's  strength  allow  of  such  treatment. 

Eventually  tapping  becomes  necessary  for  the  comfort  of 
the  patient,  although  the  operation  may  have  to  be  repeated 
frequently,  as  the  accumulation  tends  to  recur.  Care 
should  be  taken  before  tapping  to  exclude  a  distended  blad- 
der. The  skin  having  been  scrupulously  sterilized,  the 
puncture  should  be  made  with  a  straight  trocar,  in  the 
median  line  midway  between  the  symphysis  and  the  navel, 
provided  that  previous  percussion  has  not  revealed  an  intes- 
tinal coil  lying  directly  under  the  site  of  puncture.  When 
the  fluid  ceases  to  flow  the  trocar  is  to  be  withdrawn,  the 
opening  being  closed  by  a  suture  over  which  is  applied  an 
antiseptic  pad.  A  tight  many-tailed  bandage  applied  dur- 
ing the  tapping  will  facilitate  the  flow,  and  after  the  trocar 
is  withdrawn  will  yield  support  to  the  relaxed  abdominal 
wall ;  this  application  should  never  be  omitted.  The 
dangers  of  tapping  are  syncope,  perforation  of  the  intestine, 
infection  of  the  peritoneum  with  unclean  instruments,  and 
hemorrhage  from  puncture  of  an  artery  of  the  abdominal 
wall. 


5IO        MAXr.-iL    OF  THE  PRACTICE    OF  MEDICIXE. 

5.    DISEASES  OF  THE  LIVER. 

FUNCTIONAL    DISTURBANCES    OF  THE    LIVER. 

To  appreciate  the  various  symptoms  caused  b\'  functional 

disturbances   of  the    liver    it    is  necessary  to  consider  the 

normal  functions  of  the  liver,  and  to  see  what  symptoms 

will  necessarily  arise  from  the  perversion  of  each  function. 

1.  From  disturbed  glycogenic  function  the  bodily  heat  is 
lowered,  so  that  the  patient  becomes  susceptible  to  cold ; 
glucose  may  pass  the  liver  unchanged  and  may  appear  in 
the  urine  (glycosuria). 

2.  Destructive  metamorphosis  of  albuminoid  matter  not 
being  properly  performed,  uric  acid  and  sub-oxidized  urea 
compounds  are  retained  in  the  body,  giving  rise  to  head- 
ache, vertigo,  mental  dulness,  and  despondency.  Muscular 
or  articular  pains  are  common.  The  kidneys  may  become 
irritated  by  the  uric  acid  and  the  oxalate  of  lime,  and  a 
chronic  nephritis  may  develop.  In  some  cases  renal  calculi 
result. 

3.  Defects  in  the  quantity  or  the  qualit\-  of  the  bile  allow 
of  general  malnutrition.  Fats  not  being  easily  absorbed,  the 
patient  becomes  thin.  There  are  constipation  and  intestinal 
flatulence. 

4.  From  the  failure  of  the  liver  to  destroy  the  poisons 
arising  in  the  normal  processes  of  digestion  (pepto- 
toxines),  or  the  alkaloids  of  intestinal  fermentation,  these 
toxic  products  pass  the  liver  unchanged,  and  a  general 
toxajmia  is  the  result. 

Etiology. — Functional  disturbance  of  the  liver  may  be 
primary  or  secondary. 

Primary  cases  arise — (i)  From  errors  in  diet.  The  food 
may  be  too  rich,  too  excessive,  or  too  abundant  in  fatty  and 
saccharine  ingredients,  or  there  may  be  an  over-indulgence 
in  malt  liquors.  (2)  From  want  of  exercise  and  from 
deficient  oxidation-processes. 

Secondary  cases  arise — (i)  From  structural  changes  in 
the  liver.  (2)  From  disorders  of  gastric  or  intestinal  diges- 
tion.    (3)  From  disorders  of  the  heart  and  the  lungs,  inter- 


FUNCTIONAL   DISTURBANCES   OF   THE   LIVER.       5  I  I 

fcring  with  a  proper  circulation  of  blood  within  the  liver 
and  with  oxidation-processes.  (4)  Some  cases  seem  to  be 
due  to  mild  malarial  poisoning. 

Symptoms. — Individual  symptoms  may  be  inferred  from 
the  consideration  of  the  preceding  paragraphs.  Clinically 
the  cases  may  be  divided  into  two  groups  : 

1.  The  whole  nutrition  of  the  patient  is  below  par;  he 
looks  anaemic  and  imperfectly  nourished,  and  the  com- 
plexion has  a  muddy,  sallow  tinge.  The  tongue  is  furred 
and  flabby.  The  appetite  is  generally  lost,  especially  dur- 
ing the  earlier  portions  of  the  day.  The  bowels  are  con- 
stipated, the  stools  being  dryish  and  clay-colored.  There 
is  a  disagreeable  taste  in  the  mouth,  especially  in  the  morn- 
ing, variously  described  as  "bitter"  or  "pappy."  The 
breath  is  usually  offensive.  Headaches  are  frequent ;  they 
may  be  so  persistent  and  severe  as  to  suggest  organic  disease 
of  the  brain.  Attacks  of  "  sick  headache  "  incapacitate  the 
patient  from  time  to  time.  The  mental  condition  is  one  of 
apathy,  with  periods  of  irritability  and  depression.  The 
urine  generally  shows  deposits  of  urates,  of  oxalate  of  lime, 
or  of  uric  acid.  These  patients  are  commonly  described  as 
"  bilious." 

2.  Patients  of  the  second  group  of  cases  do  not  become 
emaciated  nor  do  they  lose  strength.  The  intestinal  symp- 
toms are  slight,  but  the  cerebral  symptoms  are  prominent 
and  distressing.  Vertigo  is  often  so  pronounced  that  the 
patient  is  afraid  to  leave  the  house  alone.  There  is  loss  of 
memory,  with  failure  of  the  mind  to  concentrate  itself  for 
any  length  of  time.  Headache  is  frequent  and  distressing. 
There  are  alternate  pallor  and  flushing  of  the  face,  with  a 
sense  of  throbbing  fulness  in  the  head.  The  urine  may 
contain  oxalate  of  lime,  uric  acid  or  the  urates,  or  may  be 
normal.  In  these  cases  the  symptoms  are  due  to  the  vaso- 
motor disturbances  of  the  vessels  of  the  brain,  due  to  their 
irritation  by  toxic  products  of  body- waste  or  of  intestinal 
digestion. 

The  prognosis  depends  largely  upon  the  will-power  of 
the  patient  to  carry  out  the  necessary  treatment. 

Treatment. — hxxy    dietetic    error    should    be    corrected. 


512        MA.VCAL    OF   THE   PK.ICT/CE    OF  MEDICLXE. 

The  food  should  be  simple  and  wholesome,  and  fatty  and 
starchy  food  should  be  reduced  in  quantity.  Alcoholic 
stimulants  should,  in  general,  be  interdicted.  The  most 
benefit  is  to  be  derived  from  active  exercise  in  the  open  air 
to  the  point  of  moderate  fatigue.  The  exercise,  once 
begun,  should  be  systematic,  should  be  graded  to  suit  the 
individual  strength  of  the  patient,  and  should  be  of  such 
nature  as  to  afford  pleasure  and  enjoyment.  The  drug- 
treatment  consists  chiefly  in  controlling  dyspeptic  condi- 
tions, in  giving  laxatives  when  required,  and  in  the  use  of 
cholagogues.  Of  the  latter,  podophyllin,  rhubarb,  ipecac, 
magnesium  sulphate,  hydrochloric  acid,  and  salicylic  acid 
are  the  most  serviceable.  The  modified  rhubarb  and  soda 
mixture,  while  unpleasant  to  the  taste,  is  of  great  value: 

I^.     Pulv.  rhei,  gr.  ij ; 

Sodii  bicarb.,  gr.  v  ; 

Pulv.  ipecac,  gr.  \; 

Tinct.  nucis  vomicae,        TTLv  ; 
Aq.  menth.  pip.,  ,^j. — M. 

Sig.  One  teaspoonful  three  times  daily,  before  meals. 

CIRCULATORY    DISTURBANCES    OF    THE    LIVER. 

Anaemia. — This  condition,  frequently  found  post-mortem, 
is  not  accompanied  by  any  symptoms. 

Active  congestion  was  formerly  regarded  as  a  more  im- 
portant condition  than  at  the  present  time.  Physiological 
congestion  occurs  after  a  hearty  meal.  Acute  congestion 
may  occur  with  infectious  diseases,  especially  malaria, 
typhoid  fever,   and   dysentery. 

The  syinptovis  are  not  characteristic.  There  may  be  slight 
enlargement  of  the  liver  with  tenderness  on  palpation. 

Treatment  is  by  active  purgation. 

Passive  congestion  (Chronic  congestion;  Nutmeg  liver). 
— This  condition  occurs  whenever  there  is  a  mechanical 
obstruction  to  the  outflow  of  blood  from  the  liver,  during 
the  course  of  heart  disease  with  a  failing  right  ventricle,  with 
diseases  of  the  lungs  interfering  with  the  flow  of  blood 
from  the  right  to  the  left  heart,  and  with  pressure  on  the 
vena  cava  by  thoracic  tumors. 


DISEASES   OF   TI/E    CAPSdlJi    OF   'J'J/E    LIVER,       513 

Pathology. — The  central  vein  of  each  hepatic  lobule  is 
dilated,  and  the  liver-cells  in  its  neighborhood  become  pig- 
mented and  atrophied.  The  cells  at  the  periphery  of  the 
acinus  become  fatty.  The  mottling  of  the  reddish-brown 
depressed  centre  and  the  yellowish  periphery  of  each  acinus 
gives  rise  to  the  term  "  nutmeg  "  liver.  In  long-continued 
cases  connective  tissue  may  be  deposited  in  and  between 
the  lobules,  starting  usually  from  the  central  vein.  In  the 
earlier  stages  the  liver  is  enlarged,  but  the  longer  the  conges- 
tion lasts,  the  smaller  and  denser  the  liver  tends  to  become. 

The  symptoms  are  chiefly  those  of  the  primary  lesion 
with  the  attending  venous  congestions.  There  may  be 
added  symptoms  of  a  moderate  degree  of  portal  obstruction 
(see  Cirrhosis  of  the  Liver).  Nausea,  vomiting,  and  even 
vomiting  of  blood  may  occur,  and  slight  jaundice  may  be 
evident  in  the  conjunctivae  and  in  the  urine. 

The  treatment  is  that  of  the  original  disease.  Depletion 
of  blood  from  the  liver  is  accomplished  by  vegetable  or 
saline  laxatives.  An  occasional  mercurial  purgation  by  cal- 
omel or  by  blue  pill  is  recommended. 

DISEASES  OP  THE  CAPSULE  OP  THE  LIVER. 

Acute  Perihepatitis. 

Etiology  and  Synonyms. — The  cause  of  acute  peri- 
hepatitis may  be  direct  violence,  but  usually  there  is  found 
perforation  of  an  ulcer  of  the  stomach  or  the  duodenum,  or 
infection  or  rupture  of  a  neighboring  abscess,  especially  of 
the  liver,  the  gall-bladder,  or  the  right  kidney.  Synonyms  : 
Subphrenic  abscess  ;  Subphrenic  pyo-pneumothorax. 

Patholog-y. — The  peritoneum  of  the  liver  and  of  the 
corresponding  surface  of  the  diaphragm  is  congested  and 
covered  with  fibrin  and  pus.  Adhesions  form,  allowing  of  a 
circumscribed  peritoneal  abscess  (subphrenic  abscess).  The 
pus  may  be  yellowish-red  in  color,  from  the  presence  in  it 
of  bilirubin,  and  it  may  contain  crystallized  fatty  acids.  If 
the  cause  be  a  perforation  of  an  ulcer  of  the  stomach  or  of 
the  duodenum,  the  pus  may  be  mixed  with  air  (subphrenic 
pyo-pneumothorax  j, 
33 


514        M.l.yr.tl.    OF   THE   PRACTICE    OF  MEDICINE. 

The  sjrmptoms  of  acute  perihepatitis  are  those  of  a  local-" 
ized  peritonitis.  There  are  pain  and  tenderness  with  the 
general  symptoms  of  fever.  In  perforative  cases  the  onset 
is  abrupt  and  may  be  accompanied  by  shock.  In  general, 
the  course  of  the  disease  is  that  of  an  empyema  or  an  ab- 
scess of  the  liver.  Drainage  or  evacuation  of  the  pus  may 
be  followed  by  cicatricial  contraction  of  the  abscess-wall,  so 
that  compression  may  be  produced  upon  the  liver,  the  vena 
cava,  the  bile-duct,  or  the  portal  vein. 

The  physical  signs  resemble  those  of  empyema  or  of  an 
abscess  of  the  liver.  The  right  hypochondrium  is  dis- 
tended and  motionless.  There  may  be  a  friction  sound 
detected  early  in  the  disease.  Later  the  friction  disappears 
and  is  replaced  by  dulness  or  flatness  and  absence  of  voice 
and  breathing. 

Subphrenic  pyo-pneumothorax  may  giv^e  physical  signs 
similar  to  those  arising  from  a  like  condition  above  the 
diaphragm. 

The  diagnosis  of  perihepatitis  is  readily  made,  should  the 
aspirating-ncedle  draw  ochre-colored  pus  containing  bili- 
rubin and  fatty  acids.  The  etiology  of  the  condition  also 
gives  a  clue  to  the  correct  diagnosis. 

Treatment  is  entirely  surgical,  consisting  in  opening  and 
draining  the  abscess. 

Chronic  Fibrinous  Perihepatitis. 

Etiology. — This  condition  may  follow  acute  perihepatitis 
or  may  be  chronic  from  the  start,  as  the  result  of  a 
chronic  irritation  of  a  neighboring  inflammation  or  of  long- 
continued  pressure  over  the  liver. 

Patholog-y. — The  peritoneum  covering  the  liver  is  thick- 
ened and  is  adherent  in  places  to  opposed  surfaces.  Shrink- 
age of  the  fibrous  capsule  may  result  in  atrophy  of  the  liver 
or  in  constriction  of  the  veins  or  the  ducts. 

Symptoms.— ^There  are  no  characteristic  symptoms.  A 
friction  rale  may  be  heard  over  the  liver  during  inspiration, 
but  this  sign  is  inconstant. 

The  treatment  is  that  of  the  causative  disease. 


ACUTE   rARENCIIYMATOUS  lUWATITIS.  515 

Syphilitic  Perihepatitis. 
The  various  syphilitic  lesions  of  the  liver  will  be  consid- 
ered under  the  heading  of  Syphilitic  Diseases  of  the  Liver. 

ACUTE  PARENCHYMATOUS  HEPATITIS. 

Synonyms. — Acute  yellow  atrophy  ;  Malignant  jaundice. 

Etiology. — Secondary  acute  fatty  degeneration  of  the 
liver  may  occur  with  many  of  the  infectious  diseases,  in  the 
latter  stages  of  cirrhosis  or  of  biliary  retention,  with  yellow 
fever,  and  with  phosphorus-poisoning. 

Primary  cases  are  exceedingly  rare.  Individuals  under 
thirty  years  of  age  are  more  frequently  attacked,  and 
women,  especially  during  pregnancy,  are  especially  liable 
to  the  disease.  At  times  several  cases  occur  in  one  family 
or  in  barracks,  showing  an  epidemic  tendency.  The  actual 
cause  of  the  disease  is  unknown,  although  it  is  supposed  to 
be  due  to  an  unknown  bacterial  infection. 

Pathology. — The  liver  is  reduced  from  one-third  to  one- 
half  in  size,  and  its  capsule  is  in  folds  and  wrinkles.  The 
organ  is  jaundiced  or  mottled  yellow  and  red,  the  latter 
color  representing  the  more  advanced  stages  of  the  lesion, 
in  which  all  fat  has  been  absorbed  from  the  liver-tissue. 
Microscopically  are  found  extensive  fatty  degeneration  and 
necrosis  of  the  liver-cells,  ending  in  their  ultimate  absorp- 
tion. Crystals  of  leucin,  tyrosin,  and  bilirubin  may  be 
found,  and  in  most  cases  there  is  seen  a  small-celled  infiltra- 
tion of  the  stroma.  The  body-tissues  are  deeply  jaundiced. 
The  spleen  is  large  and  soft  in  about  half  the  cases.  The 
heart-muscle  shows  granular  degeneration.  There  is  acute 
degeneration  of  the  kidney.  There  are  numerous  hemor- 
rhages throughout  the  body. 

Symptoms. — In  the  majority  of  cases  there  is  a  premoni- 
tory gastro-duodenitis,  with  nausea,  vomiting,  and  jaundice. 
The  onset  of  the  disease  itself  comes  suddenly  and  severely. 

Nervous  Symptoms. — There  is  violent  headache.  Active 
delirium,  amounting  to  mania,  may  be  so  marked  as  to 
require  physical  restraint.  The  attacks  of  delirium  become 
less  and  less  severe  and    alternate  with  periods  of  stupor 


5l6        MAXr.lL    OF   THE   PA'.tCT/CE    OF  MEDIC/XE. 

until  finall\'  the  patient  passes  into  the  typhoid  condition, 
with  low.  muttering  delirium  and  extreme  prostration. 

Jaundice,  if  not  developed  during  the  preliminary  period, 
now  becomes  noticeable.  Its  absence  is  rare.  The  sudden 
occurrence  of  jaundice  with  violent  cerebral  sj'mptoms  is 
suggestive  of  this  disease. 

Honorrliagcs  occur  in  the  subcutaneous  and  submucous 
tissues,  from  mucous  surfaces,  and  into  internal  viscera. 
Pregnant  women  abort  with  violent  post-partum  bleeding. 

Urinary  syviptonis  are  somewhat  characteristic.  The 
urine  is  diminisl^ed,  jaundiced,  and  contains  albumin  and 
casts.  Urea  is  markedly  diminished,  and  ma}'  be  altogether 
absent  in  the  latter  stages,  and  in  its  place  are  found  crystals 
of  leucin  and  tyrosin.  The  former,  occurring  in  the  form 
of  globules  resembling  fat,  is  seen  only  upon  evaporation  of 
the  urine ;  the  latter,  in  the  form  of  needles,  occurs  as  a 
spontaneous  deposit.  Leucin  and  tyrosin  are  not,  however, 
constantly  present  in  the  urine  of  this  disease. 

General  symptoms  are  not  characteristic.  The  tempera- 
ture may  be  normal,  subnormal,  or  slightly  elevated.  A 
high  ante-mortem  temperature,  however,  is  almost  always 
observed.  Vomiting  is  usually  a  prominent  symptom,  and 
blood  may  be  raised.  The  bowels  are  constipated ;  the 
stools  are  clay-colored  or  may  consist  of  blood.  The  pulse 
becomes  rapid  and  feeble,  the  typhoid  condition  becomes 
more  profound,  and  the  patient  dies,  usually  within  a  week, 
although  the  case  may  be  somewhat  more  protracted. 

Physical  examination  shows  a  rapid  diminution  in  the 
size  of  the  liver.  As  the  flabby  liver  tends  to  drop  back, 
there  may  finally  be  only  a  slight  line  of  liver-dulness  in 
the  axillary  region,  and  no  dulness  at  all  in  front.  If  the 
disease  attack  a  previously  enlarged  liver,  the  diminution 
will  be  less  marked  and  the  diagnosis  will  be  more  difficult. 
The  liver  is  usually  tender  on  palpation  or  percussion.  The 
diagnosis  is  further  aided  by  the  presence  of  an  enlarged 
spleen,  by  the  jaundice,  and  by  the  hemorrhages. 

The  diagnosis  may  be  made  positively  upon  the  associa- 
tion of  severe  jaundice,  cerebral  symptoms,  diminished  size 


CfRRIIOSJS    OF   THE    L/l'AA'.  517 

of  the  liver,  and  the  presence  of  leucin  and  tyrosin  in  the 
urine. 

The  case  may  be  mistaken  for  one  of  phosphorus-poison- 
ing, but  in  the  latter  condition  there  is  the  history  of  poison- 
ing, the  presence  of  phosphorus  in  the  vomited  matters,  the 
onset  is  more  sudden,  gastro-intestinal  symptoms  are  more 
marked,  and  leucin  and  tyrosin  are  absent  from  the  urine. 

The  latter  stages  of  hypertrophic  cirrhosis  may  resemble 
acute  yellow  atrophy,  but  the  liver  is  enlarged  and  the 
course  of  the  disease  is  essentially  chronic. 

Conditions  of  profound  jaundice  with  cerebral  symptoms 
(cholaemia)  may  so  closely  resemble  acute  yellow  atrophy 
that  a  differential  diagnosis  is  very  difficult. 

Prognosis. — The  disease  is  invariably  fatal. 

The  treatment  is  symptomatic. 

CIRRHOSIS    OF    THE    LIVER. 

Synonyms — Chronic  interstitial  hepatitis;  Fibrous  cir- 
rhosis. 

Three  forms  of  cirrhosis  of  the  liver  are  recognized :  i. 
Atrophic  cirrhosis  ;  2.  Hypertrophic  cirrhosis  ;  3.  Syphilitic 
cirrhosis.  The  "  Glissonian  cirrhosis  "  has  been  described 
under  the  heading  of  Chronic  Perihepatitis. 

Atrophic  Cirrhosis. 
Etiology. — Fibrous  disease  of  the  liver  is  almost  regu- 
larly due  to  the  action  of  irritants  brought  to  the  liver  by 
the  blood-vessels.  In  over  two-thirds  of  the  cases  the  im- 
mediate cause  is  alcohol,  especially  the  stronger  liquors. 
There  may  be  the  history  of  excessive  indulgence,  or  the 
habit  of  "  nipping  "  may  be  confessed.  In  some  cases  indul- 
gence in  the  lighter  wines  or  in  malt  liquors  may  lead  to 
the  disease.  Other  irritants  entering  the  liver  by  the  portal 
vein  may  be  adduced  as  causes  of  the  disease — highly-spiced 
food  and  the  ptomaines  and  other  alkaloids  of  intestinal 
digestion — but  upon  this  point  satisfactory  evidence  is  lack- 
ing. Cirrhosis  may  follow  rickets,  scarlet  fever,  or  typhoid 
fever,  or  may  result  from  long-continued  passive  hyper?emia 
of  the  liver.     In   coal-miners   the   disease   mav  follow  the 


5l8        MAXL\AL    OF   THE    PRACTICE    OF  MEDICLVE. 

swallowing  of  coal-dust,  which  is  deposited  as  solid  pigment 
in  the  liver.  There  has  been  described  a  senile  form  of 
cirrhosis  analogous  to  other  arterio-sclerotic  changes  in  the 
different  viscera. 

Cirrhosis  of  the  liver  is  far  more  common  in  men  tlian  in 
women,  because  of  their  more  frequent  indulgence  in  alco- 
hol. It  usually  occurs  between  the  ages  of  thirty-five  and 
sixty  years,  and  it  is  far  less  common  in  children  than  was 
formerly  supposed,  although  in  them  the  majority  of  cases 
are  of  syphilitic  origin.  It  is  a  peculiar  fact  that  cirrhosis 
is  exceedingly  rare  in  the  negro,  although  in  this  race  in- 
temperate habits  are  common.  Two  autopsies  only  of  this 
disease  have  been  made  at  the  Colored  Hospital  in  New 
York  during  the  past  twenty-five  years. 

Pathology. — The  liver  is  small,  hard,  and  dense.  Its 
weight  may  not  exceed  a  pound  or  a  pound  and  a  half 
The  surface. is  granular,  and  the  capsule  is  usually  thick- 
ened. On  section  the  organ  ma\'  be  bile-stained  or  may 
present  grayish-white  streaks  of  connective  tissue.  It  was 
owing  to  the  yellow  appearance  of  the  organ  that  the  name 
"  cirrhosis  "  {xefjf)o^,  yellow)  was  first  applied  by  Laennec. 
A  primary  increase  of  the  size  of  the  liver  does  not  occur. 
Upon  close  examination  the  essential  lesion  is  seen  to  con- 
sist of  the  -formation  of  connective  tissue  within  the  liver, 
either  loose  and  cellular  or  dense  and  fibrillated.  The 
fibrous  tissue  usually  extends  about  the  radicles  of  the  por- 
tal vein  at  the  periphery  of  the  acinus,  giving  the  organ  a 
finely  granular  appearance ;  or  the  connective  tissue  may 
surround  groups  of  acini,  resulting  in  a  coarsely  granular 
appearance.  The  tissue  may  extend  into  the  liver  from  the 
capsule  in  large  irregular  streaks  and  bands,  although  this 
arrangement  is  more  common  in  .syphilitic  cirrhosis. 

Pressure-changes  are  seen  in  the  liver-cells,  the  blood- 
vessels, and  the  gall-ducts.  The  liver-cells,  especially  at  the 
periphery  of  the  acini,  undergo  fatty  degeneration  and 
become  atrophied  or  flattened  by  pressure. 

The  rootlets  of  the  portal  vein  between  the  lobules  are 
pressed  upon  and  obliterated.  This  interference  with  the 
portal    circulation  gives    rise    to    the   important  lesions  of 


CIKRIJOSIS   OF   THE    I.IVhR.  519 

portal  obstruction.  There  is  usually  an  increase  in  the  size 
of  the  hepatic  artery  furnishing  blood  to  the  new  fibrous 
tissue.  The  gall-ducts  may  be  the  seat  of  a  catarrhal 
inflammation  or  may  become  obliterated.  In  some  cases 
there  occurs  an  irregular  production  of  new  gall-ducts. 

Secondary  lesions  result  directly  from  the  portal  obstruc- 
tion. The  spleen  becomes  congested  and  hyperplastic. 
The  stomach  and  the  intestines  are  congested  or  show 
chronic  catarrhal  inflammation.  Ascites  results  from  the 
stasis,  may  reach  an  extreme  degree,  and  may  be  accom- 
panied by  a  mild  form  of  chronic  peritonitis.  Hemorrhoids 
result  from  congestion  of  the  veins  of  the  rectum.  There 
are  evidences  of  collateral  circulation  between  the  branches 
of  the  portal  veins  and  those  of  the  vena  cava,  at  the  junc- 
tion of  the  oesophagus  and  the  stomach,  along  the  sigmoid 
flexure  and  rectum,  in  the  retroperitoneal  plexus,  and  about 
the  umbilicus.  The  radiating  varicose  veins  about  the  latter 
situation  have  received  the  name  of  "  caput  Medusae."  The 
branches  of  the  internal  mammary  and  epigastric  veins  also 
become  dilated  and  tortuous. 

Associated  lesions  are  not  due  directly  to  the  cirrhosis, 
but  are  frequently  found  in  the  same  patient,  and  arise  from 
the  same  etiological  factors  as  does  the  fibrous  disease  of 
the  liver.  These  lesions  comprise  endocarditis,  atheroma 
of  the  aorta,  endarteritis,  emphysema,  and  chronic  diffuse 
nephritis.  Acute  tuberculosis  is  a  not  infrequent  compli- 
cation. 

Symptoms. — There  may  be  an  antecedent  alcoholic 
gastritis.  When  cirrhosis  develops,  the  symptoms  present 
themselves  in  four  groups  : 

1.  Symptoms  of  functional  disturbance  of  the  liver.  The 
various  intestinal,  urinary,  cerebral,  and  nutritive  symptoms 
are  present  as  in  the  cases  previously  described,  and  cir- 
rhosis should  be  suspected  if  these  symptoms  occur  in  an 
alcoholic  subject. 

2.  Symptoms  of  obstructed  portal  circidation  are  more  dis- 
tinctive. Gastro- intestinal  symptoms  are  those  of  conges- 
tion or  chronic  inflammation,  dyspepsia,  vomiting,  haema- 
temesis  which  may  be  profuse  or  even  fatal,  constipation,  and 


520        .y.lXl'.IL    OF   THE   PRACTICE    OF  MEDIC L\'E. 

hsemorrhoids.  Ascites  gives  rise  to  enkirgement  ut  the 
abdomen  and  to  dyspnoea ;  the  transudation  may  press 
upon  the  ihac  veins,  causing  oedema  of  the  lower  extrem- 
ities. As  long,  however,  as  compensatory  circulation  is 
maintained,  the  obstructive  symptoms  are  slight  or  absent, 

3.  Symptoms  of  jaundice  are  due  to  the  obliteration  or 
catarrhal  inflammation  of  the  bile-ducts  or  to  gastro- 
duodenal  catarrh.  The  jaundice  is  rarely  marked  at  first, 
amounting  only  to  a  nuidd\',  sallow  tinge.  The  facies  is 
fairly  characteristic :  the  skin  is  dry  and  of  an  icteroid  hue ; 
the  nose  and  the  cheeks  show  distended  veins  ;  the  eyes 
are  sunken  and  watery.  From  time  to  time  attacks  of 
more  severe  jaundice  occur,  and  in  some  instances,  espe- 
cially toward  the  termination  of  the  disease,  the  jaundice 
becomes  extreme  and  is  accompanied  by  cerebral  symp- 
toms. 

4.  Symptoms  of  toxczmia  may  develop  at  any  time.  The 
patient  may  become  actively  delirious,  noisy,  and  talkative; 
or  he  may  become  stupefied,  with  periods  of  semi-coma  and 
muttering  delirium,  or  may  even  develop  convulsions. 
These  symptoms  may  be  due  to  intense  jaundice,  to  alco- 
holism, or  to  urc-emia,  while  in  other  cases  the  exact  nature 
of  the  toxaemia  cannot  be  ascertained.  The  course  of  the 
disease  is  usually  afebrile  throughout,  except  that  a  moder- 
ate temperature  may  occur  as  a  terminal  symptom.  At  no 
time  is  there  pain  or  tenderness  over  the  liver. 

Physical  examination  shows  a  diminution  in  the  size  of 
the  liver,  an  enlargement  of  the  spleen,  and  the  presence  of 
ascites  and  of  ana.stomosing  veins.  A  positive  assurance 
that  the  liver  is  actually  diminished  in  size  is  often  lacking, 
as  an  apparent  but  not  a  real,  diminution  may  be  caused  by 
the  overlapping  of  the  liver  by  an  emphysematous  lung,  or 
by  the  liver  being  tilted  upward  by  a  distended  stomach  or 
colon  ;  or  the  lower  line  of  liver-flatness  may  be  obscured 
by  tympany  from  intestinal  distention.  In  other  cases  the 
cirrhosis  may  occur  in  a  liver  previously  enlarged  by  waxy 
or  fatty  change.  The  liver  is  thus  rendered  smaller  than  its 
previous  size,  but  still  may  be  larger  than  normal  (see 
Hypertrophic  Cirrhosis).     The   enlargement  of  the  spleen 


CIRRIJOSJS   OP'   THE   LJVJCR.  $21 

is  best  determined  by  palpation,  as  the  percussion-bound- 
aries may  be  obscured  by  tympanites,  by  the  solid  or  liquid 
contents  of  the  stomach  or  the  colon,  or  by  the  ascites.  It 
is  important  to  remember  that  the  spleen  may  not  be  in- 
creased in  size  if  there  be  continued  diarrhcea  or  vomiting 
or  if  its  capsule  be  thickened   from   perisplenitis. 

Prog-nosis. — The  course  of  the  disease  is  protracted. 
The  exact  duration  of  any  given  case  cannot  be  determined 
accurately,  as  the  onset  is  insidious.  If  the  patient  abstains 
from  his  alcoholic  habit,  the  lesion  may  not  develop  further, 
so  that  he  may  live  for  years.  In  ordinary  cases  the  end  is 
reached  within  a  year  or  two  after  the  diagnosis  is  made. 
Death  may  result  from  haematemesis,  from  Bright's  disease, 
from  delirium  tremens,  from  the  cerebral  symptoms  of 
severe  jaundice,  or  from  toxaemia  and  exhaustion.  In  the 
latter  instance  the  patient  becomes  anaemic  and  emaciated, 
the  enlarged  ascitic  abdomen  being  in  marked  contrast  to 
the  emaciated  chest  and  extremities.  Cerebral  symptoms 
develop — stupor,  muttering  delirium,  and  semi-coma.  The 
pulse  becomes  rapid  and  feeble,  and  death  finally  results. 

Treatment. — The  patient  should  abstain  from  alcoholic 
drinks  and  from  highly-seasoned  food.  The  diet  should  be 
of  the  simplest  character,  and  the  value  of  a  prolonged  milk 
diet  cannot  be  overestimated.  Exercise  should  be  moder- 
ate and  gradual ;  the  skin  is  to  be  kept  active  by  baths  and 
frictions ;  the  bowels  should  be  kept  open ;  and  all  errors 
of  digestion  should  receive  appropriate  treatment.  In  pa- 
tients with  a  syphilitic  history  mercury  and  potassium 
iodide  may  be  given.  Quinine  and  arsenic  are  indicated  if 
the  patient  lives  in  a  malarial  locality.  Cholagogues  are 
indicated  for  the  relief  of  the  functional  disturbances  of  the 
liver.  When  symptoms  of  portal  obstruction  appear,  the 
indication  for  treatment  is  to  deplete  the  engorged  intestinal 
vessels  by  occasional  catharsis.  For  this  purpose  from  half 
an  ounce  to  an  ounce  of  magnesium  sulphate  may  be  given 
in  a  concentrated  solution  before  breakfast,  or  any  of  the 
vegetable  purges  may  be  administered.  An  occasional  dose 
of  calomel  or  of  blue  pill  is  also  of  service.  The  ascites  is 
to    be    relieved   by   diapharetics,   cathartics,  and    diuretics. 


522        MAXCAL    OF   THE   PKACTICE    OF  MEDICIXE. 

Tapping  should  not  be  resorted  to  unless  the  ascites  be 
distressing  and  be  unrelieved  by  medicinal  treatment,  as  the 
operatiori  usually  must  be  repeated  frequently,  and  cerebral 
symptoms  are  apt  to  follow  the  withdrawal  of  the  effusion. 
Repeated  tappings,  moreover,  may  result  in  chronic  peri- 
tonitis. Toward  the  close  of  the  disease  alcohol  may  be 
necessary  as  a  stimulant. 

Hypertrophic  Cirrhosis. 
Of  h^'^pertrophic  cirrhosis  four  forms  are  described: 

1.  In  the  first  variety  the  lesions  are  the  same  as  in  the 
atrophic  form,  but  the  increase  of  the  connective  tissue  is 
greater  than  can  be  compensated  for  by  the  atrophy  of  the 
liver-parenchyma.  The  result  is  a  cirrhotic  liver  of  large 
size.  The  secondary  lesions  and  the  symptoms  are  identical 
with  those  of  the  atrophic  form. 

2.  Biliary  cirrhosis,  or  hypertrophic  cirrhosis  ivith  jaundice, 
usually  results  from  chronic  bile-retention,  and  frequently 
follows  chronic  obstruction  of  the  common  duct  by  a  gall- 
stone, by  cicatricial  contraction,  or  by  pressure  from  without. 
A  primary  form  of  biliary  cirrhosis  has  been  described. 
The  bile-ducts  become  distended  and  are  surrounded  by 
new  deposits  of  connective  tissue.  Fatty  degeneration  and 
atrophy  of  the  liver-cells  are  not  marked,  the  lesion  differ- 
ing greatly  in  this  regard  from  that  of  the  atrophic  form. 
The  liver  is  symmetrically  enlarged,  extending  to  the  umbil- 
icus or  even  to  the  level  of  the  anterior  superior  spines,  is 
deeply  jaundiced,  and  is  resistant  to  the  feeling  and  to  the 
knife.  Secondary  lesions  of  portal  obstruction  are  usually 
present,  but  to  a  less  degree  than  in  the  atrophic  form. 
Ascites  is  usually  absent,  although  it  may  appear  late  in  the 
disease.  Jaundice  is  persistent  and  extreme  throughout, 
yet  the  feces  may  be  bile-stained.  Hemorrhages  in  biliary 
cirrhosis  are  infrequent.  At  any  time  there  may  appear 
symptoms  closely  resembling  those  of  acute  yellow  atrophy. 
The  temperature  rises  to  102°,  104°,  or  even  to  106°  or 
108°  F.,  jaundice  rapidly  becomes  more  extreme,  delirium 
and  convulsions  appear,  and  a  fatal  issue  rapidly  follows. 


CIRRHOSIS    OF   THE    LIVER.  523 

Lcucin  and  tyrosin,  however,  do  not  appear  in  the  urine. 
In  other  cases  death  results  from  emaciation  and  debility. 

The  course  of  the  disease  is  from  three  to  seven  years. 

The  treatment  is  that  of  cirrhosis  in  general.  Good  re- 
sults have  followed  the  frequent  use  of  small  doses  of  cal- 
omel, one  grain  being  given  several  times  a  day  for  several 
days,  and  then  discontinued  should  too  free  purgation  fol- 
low or  should  stomatitis  threaten,  to  be  again  administered 
after  five  or  six  days'  interval. 

3.  Fatty  Cirrhosis. — In  this  form  of  cirrhosis  fatty  and 
cirrhotic  changes  are  found  associated.  The  liver  is  large 
and  resembles  a  fatty  liver,  but  it  is  firmer,  more  resist- 
ant to  the  feeling  and  to  the  knife,  and  microscopically 
shows  an  increase  in  the  connective  tissue.  The  clinical 
course  is  that  of  atrophic  cirrhosis,  differing  only  in  the  fact 
that  the  liver  is  found  to  be  enlarged.  This  form  of  cirrhosis 
is  very  common. 

4.  There  is  a  form  of  hypertrophic  cirrhosis  accompanied 
and  usually  preceded  by  bronzing  of  the  skin.  In  many  of 
the  advanced  cases  diabetes  has  been  present,  and  to  this 
symptom-complex  the  name  "diabete  bronze"  has  been 
given.  Whether  the  disease  has  a  separate  pathological 
entity  is  uncertain.  It  is  believed,  however,  that  the  primary 
lesion  consists  in  the  widespread  deposition  of  blood-pigment 
(haemochromatosis),  with  subsequent  degeneration  of  the 
cells  containing  the  pigment,  especially  in  the  liver  and 
pancreas,  which  organs  become  the  seat  of  a  chronic  inter- 
stitial inflammation.  The  great  majority  of  the  reported 
cases  have  occurred  in  adult  males. 

Syphilitic  Cirrhosis. 

Etiology. — Syphilitic  disease  of  the  liver  may  be  the  re- 
sult of  hereditary  syphilis,  occurring  as  a  congenital  mani- 
festation or  during  childhood,  or  the  liver  may  be  affected 
as  a  tertiary  lesion  of  the  acquired  disease. 

Patholog-y. — Pathologically,  three  types  of  syphilitic  dis- 
ease of  the  liver  may  be  described,  but  they  are  usually 
combined  and  blended  with  each  other : 

1.  Syphilitic  Perihepatitis. — The  capsule   of  the  liver  is 


524      A/.ixr.t/.  0J-'  riiF.  practice  of  medicixe. 

thickened  and  is  adliercnt  to  opposing  peritoneal  surfaces. 
From  the  thickened  capsule  bands  of  connective  tissue  pass 
into  the  substance  of  the  liver,  forming  fibrous  scars  that 
cause  considerable  deformity. 

3.  Diffuse  SypJiilitic  Hepatitis. — The  liver  is  large,  firm, 
and  resistant.  Its  color  ma\-  be  compared  to  that  of  sole- 
leather,  or  its  appearance  may  resemble  that  of  the  amyloid 
liv^er.  Microscopically  the  hepatitis  does  not  present  essen- 
tial differences  from  the  lesion  of  ordinar\'  cirrhosis,  al- 
though in  some  instances  large  groups  of  acini  are  sur- 
rounded by  fibrous  bands  visible  to  the  naked  eye,  and 
extensive  puckered  cicatrices  may  be  found.  Gummata 
are  usually  present  at  some  stage  of  the  disease.  The  lesions 
of  portal  obstruction  are  regularly  present. 

3.  GuDiviata  occur  as  nodules  varying  in  size  from  that 
of  a  pea  to  that  of  a  lemon.  Fresh  gummata  are  reddish- 
gray  and  of  a  translucent  appearance.  The  older  gummata 
show  at  their  peripher\-  a  connective-tissue  capsule  ;  their 
centres  may  become  cheesy,  fibrous,  or  puriform,  or  they 
may  be  infiltrated  with  lime-salts.  Smaller  gummata  un- 
dergo fibroid  transformation  and  result  in  disfiguring  cica- 
trices. Gummata  alone  cause  neither  portal  obstruction 
nor  jaundice,  as  a  rule,  unless  they  form  in  a  locality  where 
pressure  on  the  portal  vein  or  the  bile-duct  is  possible. 

Symptoms. —  i.  Of  the  Perihepatitis. — Pain  and  tender- 
ness are  commonly  observed ;  the  movements  of  the  liver 
during  respiration  are  impeded ;  and  a  friction  sound  can 
usually  be  detected  by  auscultation. 

2.  Of  the  Diffuse  Hepatitis. — The  symptoms  resemble 
those  of  cirrhosis,  but  a  primary  enlargement  of  the  liver 
may  possibly  occur. 

3.  Of  Guunnata. — The  symptoms  are  similar  to  those 
produced  by  multiple  tumors.  The  gummata  are  usually 
situated  near  the  suspensory  ligament  and  on  the  under 
surface  of  the  liver,  so  that  an  irregular  lower  border  may  be 
appreciated.     Inequalities  of  the  surface  may  be  detected. 

The  diagnosis  of  syphilitic  disease  of  the  liver  is  made  by 
the  consideration  of  the  following  points:  i.  The  absence 
of  alcoholic  history.     2.  The  presence  of  congenital  or  the 


ABSCESS  OF  tup:  liver.  525 

late  forms  of  acquired  syphilis.  3.  The  patient  is  frequently 
a  young-  child.  4.  The  symptoms  of  cirrhosis  are  compli- 
cated by  those  of  perihepatitis  and  of  gummata.  5.  The 
beneficial  results  of  treatment. 

Treatment  consists  in  the  administration  of  potassium 
iodide  in  large  doses,  preferably  combined  with  mercurials. 
If  the  treatment  be  prompt  and  vigorous,  the  results  are 
often  brilliant;  but  if  the  treatment  be  begun  too  late,  cica- 
tricial bands  and  diffuse  hepatitis  may  remain,  for  which 
further  treatment  is  of  no  avail.  In  other  respects  the  treat- 
ment of  the  case  is  that  of  ordinary  cirrhosis. 

ABSCESS  OP  THE  LIVER  (SUPPURATIVE 
HEPATITIS). 
Etiology. — Abscess  of  the  liver  is  due  to  infection  by 
micro-organisms  capable  of  causing  suppuration.  Of  these 
micro-organisms  the  pyogenic  micrococci  and  the  amoeba 
coli  are  the  most  important.  The  infecting  germ  may  enter 
the  liver  by  several  channels  : 

1.  Through  traumatism,  by  injuries,  by  foreign  bodies, 
and  by  parasites.  Suppurating  hydatid  cysts  are  not  un- 
common. 

2.  Through  the  portal  vein.  Liver-abscess  thus  compli- 
cates intestinal  ulcerations  (especially  those  of  dysentery, 
in  which  the  infective  agent  is  the  amceba  coli),  abdominal 
abscesses,  operations  upon  the  rectum,  and  suppurative  in- 
flammations of  the  portal  vein   itself 

3.  ThrougJi  the  umbilical  vein  in  new-born  children,  fol- 
lowing infection  of  the  navel. 

4.  TlirougJi  the  hepatic  artery  in  pyaemia,  in  malignant 
endocarditis,  and  in  gangrene  of  the  lung. 

5.  Through  the  bile-duct.  Infection  through  this  channel 
is  favored  by  the  presence  of  cholangitis  or  of  gall-stones. 

6.  In  some  cases  no  cause  can  be  ascribed  for  the  infec- 
tion, and  to  these  cases  the  names  "  idiopathic  "  and  "  tropi- 
cal "  abscess  are  given.  This  variety  of  abscess,  which  is 
most  common  in  India,  may  occur  in  the  Southern  United 
States,  but  it  is  infrequent  in  Northern  cities.    The  infecting 


526     .v.-Lvr.iL  OF  riiE  practice  of  medicine. 

agent  in  most  of  these  abscesses  is  the  amteba  coh,  although 
the  symptoms  of  dysentery  may  be  absent. 

Abscess  of  the  Hver  occurs  with  greatest  frequency  in 
men,  and  in  those  of  adult  years. 

Pathology. — Tlie  wall  of  the  abscess  is  usually  irregular 
and  jagged  ;  it  is  composed  of  necrotic  liver-tissue  infiltrated 
with  fibroid  serum  and  pus,  and  the  surrounding  liver-tissue 
is  hypera^mic.  In  protracted  cases  a  connective-tissue  cap- 
sule may  be  formed.  The  pus  ma)'  be  thick  and  creamy, 
or  it  may  be  thin,  curdy,  and  of  a  reddish  or  brownish  color, 
from  pigment  derived  from  blood-cells  and  broken-down 
livcr-parench}-ma,  thus  resembling  anchovy  sauce  in  appear- 
ance. In  other  cases  the  pus  is  yellowisli-green  or  brick- 
red  in  color,  from  the  staining  of  bile  or  of  bilirubin-crystals. 
The  pus,  which  is  usually  foul-smelling,  is  generally  shown 
by  bacterial  examination  to  be  sterile.  There  may  be  but 
one  abscess,  as  in  the  tropical  variety,  or  the  abscesses  may 
be  multiple,  as  is  the  case  with  pyaemia  and  with  suppura- 
tive inflammation  of  the  portal  vein  or  of  the  bile-passages. 
Single  abscesses  may  reach  the  size  of  a  cocoanut ;  multiple 
abscesses  vary  in  size  up  to  that  of  a  walnut,  but  by  their 
coalescence  still  larger  abscess-cavities  may  be  formed. 
Seven-tenths  of  all  abscesses  of  the  liver  occur  in  the  right 
lobe,  usually  toward   the  convexity. 

Abscesses  in  the  liver  evince  a  tendency  to  approach  the 
surface  and  to  rupture.  In  5  per  cent,  of  all  cases  rupture 
into  the  peritoneal  cavity  occurs.  Usually,  however,  the 
peritoneum  is  shut  off  by  adhesions,  so  that  the  abscess 
ruptures  into  neighboring  organs.  Rupture  upward  into 
the  right  lung  occurs  in  9  per  cent.,  into  the  right  pleura  in 
5  per  cent.,  of  all  cases.  Perforation  of  the  pericardium  or 
of  the  vena  cava  may  occur.  Rupture  downward  may  occur 
into  the  liver,  the  intestine  (3  per  cent.),  or  the  kidney.  The 
abscess  may  approach  the  chest-wall  or  the  abdominal  wall 
or  may  open  into  the  gall-bladder.  In  rare  cases  the  abscess 
remains  stationary.  A  connective-tissue  capsule  is  ulti- 
mately formed,  enclosing  the  purulent  contents,  which  may 
become  inspissated  and  cheesy. 

The  symptoms  are  general  and  local. 


ABSCESS   OF   Til  J'.    IJl'J'.R.  527 

General  syviptoms  indicate  the  presence  of  pus  within  the 
body.  Chills  are  common  at  the  onset,  and  may  be  re- 
peated throughout  the  disease.  The  chills  may  be  erratic 
and  may  be  followed  by  fluctuations  in  temperature  and  by 
cold  sweating — a  symptom-complex  of  pus-infection  ;  or 
the  chills  may  be  repeated  in  multiple  abscesses  whenever  a 
new  focus  of  suppuration  forms.  The  fever  is  usually 
irregularly  remittent,  although  in  some  cases  the  remissions 
are  so  periodic  as  to  suggest  malarial  fever.  In  some  cases, 
especially  if  long-protracted,  fever  may  be  entirely  absent. 
Prostration  is  evident  from  the  first ;  the  pulse  becomes 
rapid  and  feeble,  and  the  patient  finally  passes  into  a  typhoid 
condition.  The  appearance  of  the  patient  is  somewhat 
characteristic.  The  skin  is  sallow  and  of  a  slightly  jaundiced 
hue,  and  the  expression  strongly  suggests  the  existence  of 
abscess.  Marked  jaundice  is  rare.  The  bowels  may  be 
constipated,  or  there  may  be  diarrhoea.  Amoebae  coli  may 
be  found  in  the  stools,  giving  a  clue  to  the  diagnosis.  The 
general  symptoms  may  be  so  complicated  or  masked  by 
those  of  the  primary  disease  that  no  special  features  may  be 
added  to  the  case. 

Local  symptoms,  due  to  localized  suppuration,  consist  of 
pain  and  tenderness.  The  pain  may  be  dull  in  case  of  a 
central  abscess,  or  sharp  and  cutting  if  the  peritoneum  over 
the  abscess  become  inflamed.  In  many  cases  the  inflamma- 
tion extends  from  the  peritoneum  to  involve  the  diaphrag- 
matic pleura,  so  that  a  true  pleuritic  pain  occurs.  Pain  of  a 
peculiarly  heavy,  dragging  character  usually  develops  when- 
ever the  patient  lies  upon  the  left  side.  Tenderness 
becomes  more  marked  when  the  peritoneum  over  the  liver 
is  involved.  In  deep-seated  abscess  there  may  only  be 
some  rigidity  of  the  abdominal  wall  in  the  hypochondrium. 
In  some  cases  pain  and  tenderness  are  slight  or  are  alto- 
gether absent. 

Portal  obstruction  occurs  only  if  the  abscess  happen  to 
press   upon  the  portal  vein,   but  the  symptoms  are  never 
extreme. 
,    A  catarrhal  inflammation  of  the  bile-ducts  with  jaundice 


52S        M  l.yr.lL    OF   THE   PRACTICE    OF  MEDICIXE. 

may  or  may  not  be  present,  but  the  jaundice  rarely  becomes 
marked. 

Physical  Examination. —  i.  Of  the  Large  Single  Ab- 
scess.— The  Hver  is  tender  on  palpation  and  is  irregularly 
enlarged.  There  may  be  appreciable  bulging  over  the 
abscess,  depending  upon  its  size  and  its  position.  A  large 
superficial  abscess  may  give  rise  to  fluctuation  if  the  perito- 
neal surfaces  over  the  abscess  be  adherent.  As  the 
abscess  is  usually  in  the  right  lobe  near  the  convex 
surface,  the  area  of  liver-dulness  rises  in  the  axilla,  fre- 
quently to  the  fifth  rib,  and  extends  across  the  back  on  a 
level  with  the  angle  of  the  scapula.  In  these  cases  an 
erroneous  diagnosis  of  empyema  is  frequently  made.  Large 
abscesses  of  the  upper  surface  of  the  right  lobe,  extending 
forward,  ma\'  give  rise  to  dulness  as  high  as  the  second  rib 
in  front  and  the  spine  of  the  scapula  behind,  while  the  liver 
itself  is  displaced  downward,  the  lower  edge  being  fre- 
quently as  low  as  the  level  of  the  umbilicus.  Abscesses 
of  the  right  lobe  tend  to  point  in  the  seventh  and  eighth 
spaces  in  the  mammary  line  or  below  the  costal  arch.  Ab- 
scesses of  the  left  lobe  usually  point  in  the  median  line  just 
below  the  ensiform  cartilage. 

2.  Multiple  Abscess  of  Pycsuiic  Origin. — The  liver  is 
usually  symmetrically  enlarged  and  tender.  Pointing,  fluc- 
tuation, and  bulging  are  not  observed. 

In  cases  of  doubtful  diagnosis  an  exploratory  aspira- 
tion of  the  liver  may  be  resorted  to  without  risk  if  strict 
asepsis  be  observed.  A  long  needle,  not  too  small  in  cali- 
bre, should  be  used,  and  should  be  deeply  inserted  in  the 
location  of  the  suspected  abscess.  The  aspiration  should 
preferably  be  done  under  ether. 

Course  of  Abscess  of  the  Liver. — i.  Some  abscesses  run 
a  latent  course  until  rupture  occurs.  In  other  cases  there 
are  found  at  autopsies  old  encysted  abscesses  which  gave  no 
definite  symptoms  during  the  life  of  the  patient. 

2.  In  some  cases  the  constitutional  symptoms  are  marked, 
but  the  local  symptoms  are  slight  or  are  altogether  absent. 
These  cases  are  often  mistaken  for  typhoid  fever,  malaria, 
or  tuberculosis. 


ABSCJ'ISS    ()/'■    Till:    l.lll'.K.  529 

3.  The  course  may  be  straightforward,  with  pronounced 
general  and  local  symptoms.  The  patient  dies  from  per- 
foration or  from  septicaemia  unless  the  abscess  be  opened 
and  drained. 

4.  The  abscess  may  open  into  the  right  lung.  At  the 
time  of  rupture  there  will  be  raised  an  expectoration  of  a 
reddish-brown  or  brick-dust  color,  resembling  anchovy 
sauce  (Osier),  in  which  amoebae  coli  may  be  found. 

5.  Chronic  abscesses  may  run  an  insidious  course,  with 
hectic,  loss  of  flesh  and  of  strength,  and  slight  localized 
pain  and  tenderness.  Amyloid  changes  in  the  spleen  and 
the  kidneys  are  liable  to  occur. 

6.  In  cases  of  multiple  abscesses  occurring  in  the  course 
of  pyaemia  or  malignant  endocarditis,  pain,  tenderness,  and 
moderate  enlargement  of  the  liver  may  be  the  only  addi- 
tional symptoms. 

Diagnosis. — The  evident  causation  of  the  abscess  and  the 
character  of  the  pus  obtained  by  aspiration  are  of  prime  im- 
portance in  diagnosis.  Abscess  of  the  liver  may  be  con- 
founded with  the  following  conditions : 

1.  Malarial  fever.  Here  the  plasmodium  is  found  in  the 
blood,  the  spleen  is  enlarged,  and  the  disease  yields  to  qui- 
nine. Pain  and  tenderness  over  the  liver,  if  present,  are  but 
slight. 

2.  Empyema  is  to  be  known  by  a  consideration  of  its 
cause  and  by  the  different  appearance  of  the  aspirated  pus. 
The  heart  is  displaced,  and  attendant  diseases  of  the  lung 
are  evident.  It  must  be  remembered  that  abscess  of  the 
liver  may  rupture  into  the  pleural  cavity  and  constitute  a 
genuine  empyema. 

3.  Intermittent  hepatic  fever  zvith  gall-stones.  Here  the 
clinical  picture  may  closely  resemble  abscess ;  but  pain  is 
more  sudden  and  intense,  jaundice  is  marked,  and  the  fever 
is  shorter  in  duration  and  is  interrupted  by  periods  of  apy- 
rexia.  Septic  symptoms  and  failure  in  general  nutrition  do 
not  occur. 

4.  Abscess  of  the  abdominal  wall  is  diagnosed  by  the  incon- 
siderable depth  of  the  abscess  upon  operation. 

5.  Stibphrenic  abscess  is  diagnosed  by  its  etiology  (rupture 

34 


530        .l/.l.VrJL    OF   THE   PRACTICE    OF  MEDICIXE. 

of  an  ulcer  of  the  stomach  or  of  the  duodenum,  etc.)  and  b\' 
the  frequent  addition  of  air  or  y;as  to  the  purulent  effusion. 

The  progrnosis  is  bad  unless  the  pus  be  evacuated  spon- 
taneously or  by  operation.  Multiple  small  abscesses  are 
usually  fatal.  Single  abscesses  treated  surgically  show  a 
mortality  rate  of  only  30  per  cent.  Perforation  into  the 
lung  or  into  the  gastro-intestinal  tract  is  followed  by  re- 
covery in  about  half  the  cases. 

The  treatment  is  essentially  surgical,  consisting  in  the 
opening  and  draining  of  the  abscess-cavit)\  Operative  in- 
terference is  not  usual!)'  justifiable  in  cases  of  multiple 
pypemic  abscesses,  and  the  operation  may  be  postponed  if 
perforation  into  the  lung  or  into  the  gastro-intestinal  tract 
occur,  with  good  drainage,  as  in  these  instances  spontaneous 
cure  may  follow. 

TUBERCULAR   DISEASE    OF   THE    LIVER. 

1.  Miliary  tubercles  in  the  liver  occur  almost  constantly 
with  miliary  tuberculosis,  but  they  give  rise  to  no  symptoms. 

2.  Large  tubercular  deposits  and  cheesy  masses  may 
occur,  usually  in  connection  with  tubercular  disease  of  the 
intestines  or  of  the  mesenteric  glands,  but  they  are  chiefly 
of  pathological  interest. 

3.  In  the  chronic  forms  of  tubercle  in  the  liver  there  may 
be  an  increase  of  connective  tissue.  This  "  tubercular  cir- 
rhosis," as  it  is  sometimes  called,  occurs  especially  with 
chronic  tubercular  peritonitis  and  perihepatitis,  and  gives 
rise  to  the  symptoms  of  portal  obstruction. 

NE^W  GRO^WTHS  OF  THE  LIVER. 

1.  Cavernous  angioma  is  not  uncommon,  but  usually  is 
of  no  practical  significance.  Exceptionally,  in  children, 
angioma  may  form  a  growth  of  considerable  size. 

2.  Adenoma  may  develop ;  it  runs  a  benign  course, 
although  in  some  instances  it  seems  to  merge  into  car- 
cinoma. 

3.  Leukaemic  deposits  will  be  considered  in  the  descrip- 
tion of  Leukaemia. 

4.  Sarcoma  may  occur.    This  affection  is  usually  second- 


NKIV  GROWTfPS   OF   77//-:    LIVER.  53  I 

ary,  the  skin,  tlie  eye,  and  the  bones  being  the  favorite 
seats  of  the  primary  growth.  Melanotic  sarcoma  is  not 
infrequent.  Sarcoma  usually  develops  in  small  nodules 
generally  distributed  throughout  the  liver,  and  the  clinical 
course  is  that  of  cancer. 

5.  Cancer  of  the  liver  may  be  primary  or  secondary.  The 
primary  form,  which  is  exceedingly  rare,  arises  from  the 
epithelium  of  the  bile-ducts.  It  is  three  times  as  common 
in  women  as  in  men,  and  it  is  usually  associated  with  biliary 
calculi.  Secondary  cancer  in  the  liver  may  follow — (i)  any 
cancer  in  the  distribution  of  the  portal  vein,  especially  in 
the  rectum  and  the  stomach ;  (2)  direct  extension  from 
cancer  of  the  pylorus,  colon,  pancreas,  or  omentum ;  (3) 
more  rarely  secondary  involvement  of  the  liver  complicates 
cancer  in  other  organs  at  a  distance. 

Cancer  of  the  liver  is  more  frequent  in  women  than  in 
men,  and  is  more  common  in  advanced  life. 

Pathology. — There  may  be  one  large  growth  surrounded 
by  smaller  deposits,  or  small  nodules  may  be  more  gener- 
ally distributed  throughout  the  liver.  These  nodules  may 
be  sharply  defined  or  may  fade  imperceptibly  into  the  sur- 
rounding liver-tissue.  Growths  near  the  surface  may  be 
flush  with  it  or  may  project  as  round  or  flattened  nodules,  at 
times  presenting  a  central  crater-like  depression,  the  so- 
called  "  umbilicated  appearance."  Hemorrhages  may  occur 
into  the  nodules,  and  there  is  a  tendency  to  fatty  degenera- 
tion of  the  cancer-cells.  There  is  an  infiltrating  form  in 
which  small  cancer-masses,  varying  in  size  from  3  to  10 
millimeters  in  diameter,  are  scattered  throughout  the  liver, 
surrounded  by  fibrous  tissue.  The  appearance  of  such  a 
liver  closely  resembles  that  of  cirrhosis.  Symptoms  of 
portal  obstruction  may  or  may  not  be  present,  according  to 
whether  or  not  the  growths  happen  to  press  on  the  portal 
vein.  Large  or  multiple  growths  may  thus  exist  without 
the  slightest  symptom  of  portal  pressure.  In  a  little  less 
than  half  the  cases  there  is  associated  a  catarrhal  inflamma- 
tion of  the  bile-ducts,  with  jaundice. 

Symptoms. — In  cases  in  which  the  secondary  growths  are 
small  neither  mechanical   nor  functional  symptoms  are  pre- 


53-        .U.l.Vr.lL    OF   THE    PRACTICE    OF  .^fEDICEYE. 

sented.  and  the  disease  runs  a  latent  course.  This  chnical 
form  occurs  especiall}'  in  cases  in  which  the  s\-mptoms  of 
the  primary  growth  are  marked.  Should  the  disease  run  a 
more  classical  course,  the  symptoms  of  the  cancer  in  the 
liver  are  preceded  usually  by  those  of  the  primary  growth. 
When  secondary  deposits  occur  in  the  liver,  the  primary 
cancer,  especially  if  it  be  in  the  intestines  or  in  the  rectum, 
is  apt  to  cease  developing  and  may  be  overlooked.  Many 
so-called  "primar\-"  cancers  of  the  liver  are  found  to  be 
secondary  to  a  small  quiescent  cancerous  nodule  in  the 
rectum. 

The  symptoms  of  cancer  of  the  liver  may  be  classified  as 
follows  : 

1.  There  are  present  the  symptoms  oi  d.  functional  disturb- 
ance of  the  liver. 

2.  Symptoms  of  the  cancer  itself  Tire  local  and  general. 
Local  symptoms  consist  of  pain  and  tenderness.    The  pain 

is  usually  steady  and  severe,  with  paroxysms  running 
through  the  liver  to  the  back,  and  at  times  to  the  right 
shoulder.     Tenderness  is  usually  marked. 

The  general  symptoms  are  those  of  cancerous  cachexia. 
The  temperature  shows  a  slight  elevation  in  some  cases  to 
iOO°  or  102*^  F.,  and  may  be  intermittent  with  rigors. 
There  is  usually  some  oedema  of  the  feet,  the  face  is  of  a 
waxy  pallor,  and  loss  of  flesh  and  of  strength  becomes 
progressive.  Should  the  local  symptoms  be  slight,  the 
general  cachexia  may  be  mistaken  for  that  of  anaemia  or 
of  nephritis.  There  is  usually  gastric  disturbance,  with  loss 
of  appetite,  nausea,  and  vomiting.  The  cachectic  condition 
rapidly  becomes  marked,  as  the  patient  has  usually  suffered 
for  some  time  from  the  primary  growth,  and  in  some  cases 
the  cachexia  may  even  precede  the  enlargement  of  the  liver. 

3.  Symptoms  of  portal  obstruction  may  or  may  not  be 
present,  as  previously  explained.  Ascites  is  uncommon, 
but  it  may  result  either  from  portal  obstruction  or  from  can- 
cerous disease  of  the  peritoneum.  An  enlargement  of  the 
spleen  occurs  in  about  half  the  cases. 

4.  Jaundice  is  present  in  less  than  half  the  cases.  The 
symptom  is  rarely  severe,  except  in  occasional  acute  attacks. 


A'Kir  GRowj'Jis  oi'  77//':  /./17:a'.  533 

The  beeswax  appearance  of  the  skin  may  resemble  jaundice, 
but  the  conjunctiv<Te  and  the  urine  are  not  discolored. 

Physical  Examination. — The  liver  is  regularly  enlarged, 
especially  in  cases  of  multiple  growths,  and  in  extreme  cases 
may  extend  from  the  third  rib  to  the  iliac  spines.  Usually, 
however,  the  enlargement  does  not  extend  below  the  umbil- 
icus. The  margin  of  the  liver  is  irregular  and  nodular,  and 
the  contour  of  the  lower  border  can  usually  be  distinctly 
appreciated  by  palpation.  The  nodular  edge  moves  during 
inspiration  and  is  continuous  with  the  liver-dulness,  thus 
distinguishing  it  from  the  tumor-like  feeling  of  a  rolled-up 
omentum  or  from  growths  or  cysts  of  the  pancreas. 
Growths  of  the  pancreas  may,  however,  become  adherent  to 
the  liver,  so  that  a  positive  diagnosis  cannot  be  made  in 
every  case.  The  nodules  upon  the  surface  of  the  liver  may 
often  be  felt  through  the  abdominal  wall,  and  in  clear-cut 
cases  the  central  depression  maybe  appreciated.  The  infil- 
trating form — "  cancer  with  cirrhosis  "  (Osier) — may  lead  to 
much  enlargement  of  the  liver,  and  the  outlines  may  be 
symmetrical.  Tenderness  is  rarely  absent,  and  is  of  much 
diagnostic  value.  The  spleen  is  enlarged  in  half  the  cases, 
and  there  may  be  the  physical  signs  of  a  slight  amount  of 
ascites.  Important  aid  in  diagnosis  is  afforded  by  the  detec- 
tion of  the  primary  growth.  Primary  cancers  of  the  stomiach 
or  the  oesophagus  usually  make  themselves  evident,  but 
primary  growths  in  the  rectum  and  in  the  intestines  may 
easily  be  overlooked.  A  rectal  examination  should  be  made 
in  every  case  of  an  enlarged  and  tender  liver  in  which  the 
diagnosis  is  obscure. 

The  duration  of  cancer  of  the  liver  is  rarely  over  one 
year ;  it  may  even  be  shorter  than  this,  as  the  liver  may  be 
involved  late  in  the  course  of  primary  visceral  cancer  else- 
where. As  a  practical  rule,  cancer  may  be  excluded  if  a 
patient  with  an  enlarged  liver  be  in  fair  condition  at  the  end 
of  a  year. 

The  prognosis  is  invariably  fatal. 

Treatment  is  symptomatic.  Opium  may  be  given  freely 
to  relieve  the  pain. 


534        MAXCAL    OF   THE   PRACTICE    OF  MEDICINE. 

HYDATID    OF    THE    LIVER. 

Etiolog-y  a,nd  Synonym. — The  echinococcus  is  the  larval 
stage  of  the  tapeworm,  taenia  echinococcus,  found  in  the 
intestine  of  the  dog  and  the  wolf.  The  adult  worm,  which 
is  4  or  5  millimeters  in  length,  consists  of  a  head  with 
four  suckers,  a  double  row  of  hooklets,  and  four  links ; 
the  last  link,  being  alone  mature  and  containing  the  eggs, 
is  thrown  off  in  the  dejecta,  and  contaminates  the  food  or 
the  drink  taken  by  man.  The  disease  is  very  common  in 
Iceland,  where  dogs  are  allowed  great  household  privileges, 
one-seventh  of  all  deaths  in  that  country  being  due  to 
hydatid  disease.  In  Australia  and  in  Europe  the  disease  is 
not  uncommon,  but  it  is  exceedingly  rare  in  America. 
Synonyfti :  Echinococcus  cyst. 

Patholog-y. — Entering  the  intestine  by  contaminated  water 
or  food,  the  embryo  is  carried  by  the  portal  vein  to  the  liver, 
where  it  ma}'  lodge  ;  or  it  may  pass  through  the  liver,  enter 
the  vena  cava,  and  become  lodged  in  more  distant  parts. 
In  the  liver  it  grows  to  form  a  cyst  which  may  be  unilocular 
or  multilocular.  The  cyst-wall  is  composed  of  two  distinc- 
tive layers — an  outer  layer,  of  a  fine,  structureless,  laminated 
membrane  peculiar  to  hydatid  cyst,  and  an  internal  granu- 
lar layer,  the  "  endocyst."  In  time,  surrounding  the  cyst 
there  is  gradually  developed  a  capsule  of  connective  tissue. 
The  cyst  is  filled  with  a  clear,  non-albuminous  fluid  contain- 
ing sodium  chloride  and  a  trace  of  sugar ;  the  specific  gravity 
of  this  fluid  varies  between  1005  and  1015.  After  the  cyst 
has  grown  for  from  four  to  six  months  and  has  attained  the 
size  of  a  walnut,  there  develop  from  the  inner  granular  layer 
little  pediculated  vesicles,  the  walls  of  which  are  identical 
with  those  of  the  primary  cyst,  and  which  are  known  as 
"  brood-capsules."  These  brood-capsules  contain  a  number 
of  echinococcus  heads  or  "  scolices."  Each  scolex,  consist- 
ing of  a  head,  suckers,  and  hooklets,  may  project  into  the 
cavity  of  the  brood-capsule  or  may  retract  or  invaginate 
itself  so  as  to  form  a  prominence  upon  the  outer  side  of  the 
capsule.  Cysts  may  form  within  the  parent-cysts  (daugh- 
ter-cysts),   and    smaller   cysts    (granddaughter-cysts)    may 


IIVDA'ni)    ()/''    I'JII:    LIVER.  535 

develop  within  these.  Some  of  the  cysts  may  be  sterile, 
containing  no  scolices.  The  daughter-  and  granddaughter- 
cysts  may  remain  connected  with  the  ancestral  cyst-wall, 
but  in  time  they  tend  to  free  themselves.  Free  booklets  are 
often  found  ;  they  are  of  absolute  diagnostic  value  when  de- 
tected in  the  fluid  obtained  by  an  exploratory  aspiration. 

In  the  multilocular  form  of  hydatid  disease  the  secondary 
cysts  are  surrounded  with  fibrous  tissue,  so  that  there  is 
formed  a  large  irregular  tumor  of  connective  tissue  arranged 
in  septa,  enclosing  spaces  in  which  are  found  the  cysts ; 
these  spaces  may  also  contain  gelatinous  material.  The  cysts 
are  usually  sterile.  The  peculiar  characteristics  of  the  mul- 
tilocular form  are  attributed  to  the  growth  of  the  brood-cap- 
sules outward  (exogenous  cysts)  into  the  tissues  of  the  liver. 

The  growth  of  hydatid  cysts  is  exceedingly  slow,  ex- 
tending over  many  years.  In  some  cases  spontaneous  cure 
occurs — a  connective  tissue  capsule  is  formed,  the  cyst-wall 
becomes  calcified,  and  the  contents  become  putty-like  and 
may  contain  free  booklets.  In  other  cases  rupture  may 
occur  in  any  direction.  In  a  few  cases  the  cyst  suppurates 
and  assumes  the  character  of  an  abscess  of  the  liver. 

Symptoms. — In  the  majority  of  cases  the  symptoms  are 
purely  mechanical,  due  to  the  enormous  enlargement  of  the 
liver,  and  consist  of  a  sense  of  weight  and  dragging  and  of 
dyspnoea.  There  may  be  pressure  on  the  portal  vein,  with 
symptoms  of  its  obstruction — enlargement  of  the  spleen, 
gastro-intestinal  disturbances,  and  ascites.  Pressure  on  the 
bile-ducts  causes  obstructive  jaundice.  Pressure  on  the 
vena  cava  may  result  in  oedema  of  the  legs.  Suppuration 
of  the  cysts  is  attended  by  the  symptoms  of  pyaemia  and 
of  abscess  of  the  liver.  In  the  multilocular  variety  portal 
obstruction  and  jaundice  are  not  uncommonly  observed. 
Rupture  into  the  pericardium,  the  pleura,  the  peritoneum, 
the  gall-bladder,  or  the  vena  cava  is  usually  attended  by  a 
fatal  result.  Rupture  into  the  lung  may  allow  of  partial 
drainage  of  the  cyst,  or  may  be  complicated  by  pneumonia, 
abscess,  or  gangrene  of  the  lung.  Recovery  may  also  fol- 
low rupture  into  the  alimentary  tract  or  through  the  abdom- 
inal wall. 


536        M.IXC.II.    OF   THE   PR.ICT/CF    OF  MEDIC  I XE. 

Physical  Examination. — Tlicrc  is  usually  ccwsiderable 
bulging  in  the  epigastriiun  or  in  the  hypochondiiuiii.  The 
liver  is  much  increased  in  size,  so  that  it  may  extend  from 
the  second  rib  to  the  pelvis.  The  enlargement,  however,  is 
not  uniform,  so  that  the  outline  of  the  liver  is  exceedingly 
irregular.  Deep-seated  cysts  give  rise  to  an  elastic  feeling 
on  palpation ;  superficial  cysts  give  rise  to  fluctuation. 
Usually  the  surface  of  the  tumor  is  smooth  and  free 
from  all  irregularities.  An  "  hydatid  fremitus,"  resembling 
the  quivering  of  jelly,  may  be  detected.  According  to 
Murchison,  this  fremitus  is  not  due  to  the  striking  of  a 
daughter-cyst  against  the  parent-wall,  as  it  may  be  detected 
in  barren  hydatids,  but  may  be  elicited  over  any  large  cyst 
with  thin,  tense  walls  and  fluid  contents  ;  however,  as  the 
only  cysts  occurring  in  the  liver  with  these  characteristics 
are  hydatids,  the  fremitus  is  of  much  diagnostic  value.  Un- 
fortunately, the  sign  is  not  always  present.  Exploratory  aspi- 
ration renders  the  diagnosis  positive  from  the  character  of 
the  watery  contents,  by  the  presence  of  free  hooklets,  and 
by  the  occasional  presence  of  small  rolled-up  bits  of  the 
outer  laminated  membrane. 

The  prognosis  is  rendered  grave  by  the  possible  compli- 
cations that  may  ensue. 

Treatment  is  entirely  surgical.  The  older  methods  of 
treatment  by  aspiration  and  the  injection  of  iodine  have 
been  abandoned  altogether. 

FATTY    LIVER. 

Two  varieties  of  fatty  liver  are  recognized — fatty  infiltra- 
tion, in  which  the  fat  is  derived  from  some  constituent  of 
the  food,  and  fatty  degeneration,  in  which  the  fat  is  due  to 
changes  occurring  within  the  liver-cell.  The  latter  form 
occurs  with  phosphorus-poisoning,  yellow  fever,  and  acute 
yellow  atrophy  of  the  liver. 

Etiology. — Fatty  liver  may  be  physiological  after  a 
hearty  meal  and  during  lactation.  The  disease  occurs  with 
habitual  over-eating,  especially  of  fatty  and  starchy  food, 
with  intemperance  (frequently  associated  with  cirrhotic 
changes),  and  with  indolent  and  sedentary  habits,  especially 


FATTY  /./I'FA'.  537 

in  those  who  over-eat.  It  is  common  with  cachectic  con- 
ditions and  wasting  diseases  in  which  the  oxidation-pro- 
cesses are  defective.  Thus  it  frequently  occurs  with  phthi- 
sis and  with  profound  aUcEmias,  and  less  commonly  with 
rickets.  The  disease  occurs  at  all  ages,  and  is  more 
common   in   females  than   in  males. 

Pathology. — The  liver  is  enlarged  to  such  an  extent  that 
its  lower  border  usually  reaches  the  umbilicus ;  it  may  even 
be  larger  than  this.  The  margins  are  rounded,  and  the  organ 
shows  a  greasy  appearance.  The  specific  gravity  of  the 
liver  may  be  so  low  that  the  organ  will  float  in  water.  Cut 
sections  are  anaemic  and  of  a  yellowish  color,  and  the  knife 
is  smeared  with  fat;  the  stroma  is  normal.  The  lesion  may 
be  complicated  by  catarrhal  inflammation  of  the  bile-ducts. 

Symptoms. — The  disease  may  run  a  course  without 
symptoms,  or  there  may  be  disturbances  in  the  functional 
activity  of  the  liver,  with  a  sense  of  weight  and  fulness  in 
the  hypochondrium.  In  some  cases  there  is  pain  when  the 
patient  lies  upon  the  left  side,  from  the  mechanical  stretch- 
ing of  the  peritoneal  ligaments.  Portal  obstruction,  marked 
jaundice,  and  pain  and  tenderness  are  absent  in  this  disease. 
In  exceptional  cases,  however,  fatty  liver  does  not  run  the 
benign  course  usually  ascribed  to  it,  but  becomes  a  formid- 
able disease. 

1.  In  some  cases  the  symptoms  of  functional  disturbance 
are  marked,  symptoms  of  fatty  heart  are  present,  and  there 
is  a  chronic  gastritis,  possibly  with  attacks  of  haematemesis. 
The  patient  becomes  emaciated  and  dies  exhausted.  These 
cases  somewhat  resemble  cancer  of  the  liver,  but  are  unac- 
companied by  pain. 

2.  Other  patients  at  some  time  develop  acute  gastritis  of 
a  severe  type,  with  cerebral  symptoms,  weak  heart,  and 
possibly  haematemesis.  These  attacks  of  gastritis  are  fre- 
quently fatal. 

3.  Symptoms  of  a  malignant  jaundice  may  develop,  al- 
though the  autopsy  fails  to  reveal  obstruction  of  the  bile- 
ducts.  These  attacks  of  jaundice  resemble  those  occurring 
in  the  latter  stages  of  biliary  cirrhosis,  and  are  usually  fatal. 

Physical  Examination. — The  liver  is  symmetrically  en- 


53^        .^f.l\L-AL    OF   THE   PRACTICE    OF  MEDIC/XE. 

larged,  but  it  rarely  reaches  below  the  umbilicus,  as  does 
the  waxy  liver.  The  organ  is  soft  and  smooth  on  palpation, 
and  the  iQwer  edge  is  distinctly  rounded.  There  is  neither 
ascites  nor  enlarged  spleen.  Examination  is  frequently 
unsatisfactory  because  of  the  obesity  of  the  patient. 

The  prognosis  is  bad  for  recover)',  but  the  patient  may 
live  for  years.  The  fatt\'  liver  of  wasting  diseases  may 
hasten  the  fatal  issue  by  interfering  with  the  patient's  nutri- 
tion. The  occurrence  of  fatal  gastritis  or  jaundice  must 
always  be  considered  in  giving  a  prognosis. 

The  treatment  is  that  of  the  original  cause.  Exercise  is 
to  be  regulated  and  enforced  in  those  indolently  inclined ; 
the  use  of  fat,  sugar,  and  starch  should  be  restricted,  and  a 
diet  of  lean  meat,  green  vegetables,  and  milk  is  to  be  recom- 
mended. Indulgence  in  alcoholic  or  malt  liquors  is  to  be 
prohibited.  The  medicinal  treatment  is  that  of  functional 
disturbance  of  the  liver.  In  phthisical  patients  the  condition 
of  the  liver  should  not  be  treated,  but  superalimentation, 
especially  by  means  of  fat,  cream,  and  cod-liver  oil,  should 
be  continued  notwithstanding  the  effect  of  such  a  diet  upon 
the  fatty  infiltration  of  the  liver. 

AMYLOID    LIVER. 

Etiology  and  Synonyms. — This  condition  arises  from 
long-continued  suppuration,  especially  of  the  lungs  or  the 
bones.  It  occurs  with  constitutional  syphilis,  it  may  follow 
rickets  or  prolonged  convalescence  from  infectious  fevers, 
and  it  may  complicate  cancerous  cachexia.  Synonyms : 
Waxy  liver;    Lardaceous  liver. 

Pathology. — The  liver  is  symmetrically  enlarged,  the 
lower  border  being  frequently  found  below  the  navel.  The 
organ  is  firm  and  hard ;  its  lower  edge  is  sharp.  The 
cut  section  is  anaemic,  and  in  places  shows  a  translucent 
appearance  resembling  raw  bacon.  The  am)'loid  areas  are 
stained  mahogany-brown  by  dilute  watery  solutions  of 
iodine.  The  amyloid  change  begins  first  in  the  small  blood- 
vessels and  extends  to  the  connective-tissue  stroma.  The 
liver-cells  do  not  become  waxy,  but  they  may  be  atrophied 
b\'  pressure  or  may  undergo   fatty  degeneration.     Similar 


JAUNDICE.  539 

waxy  changes  are  found  in  other  viscera,  especially  in  the 
spleen  and  the  kidney. 

Symptoms. — There  are  no  characteristic  symptoms. 
Jaundice  does  not  occur.  There  is  no  portal  obstruction, 
unless  the  portal  vein  be  compressed  by  an  enlarged  waxy 
gland  in  the  hilum  of  the  liver. 

Physical  examination  reveals  a  symmetrical  painless 
enlargement  of  the  liver.  As  the  patient  is  usually  emaci- 
ated, the  detection  of  the  enlargement  is  never  difficult,  and 
the  sharp  lower  edge  may  be  appreciated  distinctly.  The 
spleen  is  enlarged,  and  the  waxy  condition  of  the  kidney 
is  made  evident  by  the  passage  of  an  increased  amount  of 
urine  containing  albumin,  and  generally  by  oedema  of  the 
lower  extremities. 

Prognosis  and  treatment  are  those  of  the  causative 
disease. 

JAUNDICE    (ICTERUS). 

Etiology. — Two  varieties  of  jaundice  are  described.  The 
first,  the  obstructive  or  hepatogenous  jaundice,  is  due  to 
obstruction  of  the  bile-ducts  and  results  from  the  absorption 
of  the  bile-pigments.  The  second  or  h(Ematogenous  variety 
includes  those  cases  of  jaundice  in  which  no  obstruction 
exists.    The  causes  of  jaundice  are  thus  classified : 

I.  Obstructive  or  Hepatogenous  Jaundice. — {a)  Foreign 
bodies  within  the  duct — gall-stones,  inspissated  bile,  para- 
sites, and  bodies  entering  from  the  duodenum. 

{B)  CatarrJial  infianiniation  of  the  bile-passages  or  of  the 
duodenum. 

{c)  Stricture  or  obliteration  of  the  conwion  duct,  congenital 
and  cicatricial. 

id')  Pressure  on  the  duct  from  zvitjwut — (i)  from  enlarged 
glands  in  the  hilum  of  the  liver  ;  (2)  from  neighboring  tumor, 
as  of  the  liver,  stomach,  or  pancreas  ;  (3)  from  large  abdom- 
inal tumors,  as  aneurysm  of  the  abdominal  aorta,  fecal 
impaction,  ovarian  tumor,  and  pregnancy;  (4)  from  con- 
tracting peritoneal  bands  and  thickening ;  (5)  from  lowering 
of  the  blood-pressure  in  the  liver  so  that  it  is  less  than  the 


540        J/.l.vr.l/.    OF   THE    PR.ICTJCE    OF  MEDIC IXE. 

pressure  of  the  bile  within  the  smaller  ducts,  as  in  mental 
shocks  and  cerebral  concussion. 

2.  Xoii-obstnictk'C  or  Hccmatogcnous  Jaundice. — The  fol- 
lowing classification  is  given  by  Osier : 

{(i)  From  widespread  necrosis  of  liver-cells,  interfering 
with  their  bile-forming  function,  as  in  acute  yellow  atrophy 
and  in  certain  cases  of  hypertrophic  cirrhosis. 

[It)  The  toxic  form.  The  poisons  of  )'ellow  fever,  Weil's 
disease,  malaria,  tj'phoid  fever,  epidemic  jaundice,  p}'a;mia, 
snake-bites,  chloroform,  ether,  phosphorus,  and  mercury 
cause  such  an  increased  destruction  of  the  blood-cells 
(haemolysis)  that  more  blood-pigment  is  set  free  than  can 
be  eliminated,  and  is    retained  in  the  tissues. 

Symptoms. —  i.  Of  Hepatogenous  Jaundice. — The  jaun- 
dice first  appears  in  the  conjunctivae  and  the  urine,  and  then 
appears  in  the  skin  and  the  mucous  membranes.  The  color 
of  the  skin  varies  from  a  canary-yellow  to  an  orange-green  or 
even  to  a  greenish-black.  The  constant  tinting  of  the  con- 
juncti\-a;  and  the  presence  of  bile-pigment  in  the  urine  dis- 
tinguish jaundice  from  all  other  pigmentations  or  stainings 
of  the  skin.  The  urine,  which  is  deeply  bile-stained  and  is 
often  of  a  brownish  color  resembling  porter,  foams  readily, 
and  the  froth  is  yellow ;  it  stains  linen  and  reacts  to  Gmelin's 
test.  The  abundant  yellow  foam  distinguishes  the  urine  of 
jaundice  from  urine  discolored  by  the  internal  use  of  rhu- 
barb or  of  santonin.  Hyaline  tube-casts  are  not  uncommon, 
and  in  severe  or  protracted  cases  there  may  be  a  moderate 
amount  of  albumin  in  the  urine.  The  perspiration  is  bile- 
stained  and  will  stain  linen,  but  the  saliva,  the  tears,  and  the 
milk  are  not  discolored.  Pruritus  of  the  skin  is  severe  and 
distressing,  especially  in  protracted  cases.  Digestive  dis- 
turbances arise  from  the  fact  that  no  bile  passes  into  the 
intestine.  The  assimilation  of  fats  is  interfered  with,  so  that 
the  patient  loses  flesh  and  becomes  anaemic.  There  is  a 
bitter  taste  in  the  mouth  ;  the  tongue  is  heavily  furred. 
Abdominal  flatulence  develops.  The  bowels  are  usually 
constipated,  although  diarrhoea  may  occur  if  fermentative 
changes  take  place  within  the  intestine.  The  stools  are 
cla\--colored,  pasty,  or  putty-like,  and  are  usualh'  offensive. 


JAUNDICE.  541 

The  heart-action  is  slower  and  more  forcible  than  normal, 
in  severe  cases  falling  to  40,  or  even  to  20,  in  the  minute. 
The  slowness  of  the  pulse  is  best  observed  when  the  patient 
is  resting,  as  the  heart-action  may  become  rapid  and  feeble 
upon  exertion.  There  is  no  fever  with  simple  jaundice ;  on 
the  contrary,  the  temperature  is  more  apt  to  be  subnormal 
— 96°  or  97°  F.  In  severe  or  protracted  cases  there  is 
developed  a  tendency  toward  hemorrhage.  Purpuric  spots 
and  ecchymoses  appear  beneath  the  skin  and  the  mucous 
membranes,  and  hemorrhages  from  free  mucous  mem- 
branes may  occur,  especially  from  the  nose,  the  stomach, 
and  the  intestines.  The  hemorrhagic  tendency  may  be  so 
extreme  as  to  preclude  surgical  treatm.ent,  as  in  operations 
the  bleeding  from  the  incision  may  become  uncontrollable. 

Cerebral  symptoms  are  almost  constant.  In  mild  cases 
there  are  persistent  headache,  irritability  of  temper,  and 
utter  inability  to  concentrate  the  mind.  Severe  cerebral 
symptoms  resemble  those  occurring  with  uraemia,  and  com- 
prise delirium,  convulsions,  stupor,  and  coma ;  or  the  patient 
may  pass  into  the  typhoid  condition  with  hemorrhages. 
The  temperature  in  these  severe  cases  may  be  as  low  as 
%']°  F.,  but  a  high  ante-mortem  rise  to  106°  or  108°  F.  is 
commonly  observed.  To  these  severe  cases  with  cerebral 
symptoms  the  names  "  pernicious  jaundice,"  "  cholaemia," 
"  acholia,'  and  "  cholesteraemia  "  have  been  given.  The 
best  explanation  of  these  cases  is  given  by  Frerichs,  who 
ascribes  the  toxaemia  to  the  pernicious  influence  of  unknown 
substances  which,  under  normal  conditions,  should  be 
elaborated  by  the  liver  into  bile. 

2.  Of  H(Bmatogenoiis  Jaundice. — The  symptoms  are  often 
obscured  by  those  of  the  primary  disease.  As  a  rule, 
the  tint  of  the  skin  is  lemon-colored.  The  urinary  pig- 
ments are  usually  increased,  but,  as  a  rule,  bile-pigment 
is  not  found  in  the  urine.  As  bile  enters  the  intestine,  the 
stools  do  not  become  clay-colored.  The  pulse  is  not  gen- 
erally lowered  in  frequency,  but  in  the  toxic  form  severe 
cerebral  symptoms  are  apt  to  develop. 

The  treatment  of  jaundice  as  a  symptom  will  be  given 
under  the  heading  of  Catarrhal  Jaundice. 


54-      .v.lvlal  of  tjie  pkaciice  of  mediclxe. 

Acute  Febrile  Jaundice. 
(See  Weirs  Disease^ 

Catarrhal  Jaundice. 

Etiolog-y  and  Synonym. — This  most  common  disorder 
is  due  to  the  closure  of  the  terminal  end  of  the  common  bile- 
duct  by  swelliui^  or  b}^  a  plug  of  mucus  during  the  course  of 
an  acute  gastro-duodcnitis.  The  inflammation  in  some  cases 
extends  upward  along  the  common  bile-duct.  The  gastro- 
duodenitis  is  usuallj'  due  to  some  dietetic  error.  It  may- 
occur  at  any  age,  but  it  is  especially  frequent  in  young 
people.  The  occurrence  of  the  duodenal  catarrh  is  favored 
by  portal  obstruction  and  by  chronic  heart  disease.  Such  is 
the  low  tension  of  the  bile  within  the  duct  that  a  very  mod- 
erate amount  of  swelling  or  occlusion  prevents  the  bile  from 
entering  the  intestine  and  results  in  obstructive  jaundice. 
SynonyDi :  Gastro-duodenitis. 

The  symptoms  are  those  of  gastritis  and  of  jaundice. 
The  gastric  s\'mptoms  are  the  first  to  appear,  and  begin 
insidious!}'  with  malaise,  loss  of  appetite,  nausea,  and  vomit- 
ing. The  bowels  are  usually  constipated.  There  may  be 
epigastric  pain  and  tenderness.  Mild  cases  are  unaccom- 
panied by  fever,  but  in  the  more  severe  forms  there  may  be 
a  temperature  of  from  ioo°  to  102°  F.  After  the  gastric 
symptoms  have  lasted  for  a  few  days  jaundice  appears,  but 
the  deeper  greenish-yellow  tints  are  not  seen.  The  regular 
symptoms  of  jaundice  are  present,  as  described  in  the  pre- 
ceding article.  After  about  a  week  the  patient  begins  to 
improve  and  the  gastric  symptoms  become  less  marked. 
The  jaundice  is  slower  in  disappearing,  so  that  the  whole 
duration  of  the  disease  is  usually  from  four  to  eight  weeks. 
There  are  mild  cases  in  which  jaundice  may  be  the  first, 
and  even  the  only,  symptom,  and  the  jaundice  may  termi- 
nate within  two  weeks. 

The  diagnosis  is  usually  made  with  ease.  Doubt  should 
be  attached,  however,  to  those  cases  in  which  the  jaundice 
persists  for  over  three  months.  There  are  cases  in  which 
constitutional   symptoms  are  marked  at  the  onset,  closely 


ci/i)f.  /:/./77//.-ts/s.  543 

resembling  typhoid  fever,  but  the  ai^pearancc  of  jaundice 
should  render  the  diagnosis  clear. 

The  prognosis  is  good.  It  is  well  at  first  not  to  make 
a  positive  [)rognosis  as  to  the  duration  of  the  attack,  as  the 
condition  may  be  mistaken  for  catarrhal  cholangitis.  In  ex- 
ceptional cases  gastro-duodenitis  with  jaundice  may  occur 
in  a  patient  who  has  a  fatty  or  cirrhotic  liver,  and  may  ter- 
minate fatally. 

Treatment. — No  very  active  treatment  is  indicated  in  the 
mild  cases.  The  patient  is  better  for  keeping  about,  in  spite 
of  his  prominent  color.  The  treatment  is  in  the  main  that 
of  an  acute  gastric  catarrh.  Cholagogues  are  of  great 
service,  provided  that  by  their  administration  the  gastritis 
is  not  aggravated.  Of  the  cholagogues,  the  best  is  sodium 
phosphate  in  3j  doses  before  meals.  Benzoic  acid,  sodium 
benzoate,  sodium  salicylate,  small  doses  of  rhubarb,  and  an 
occasional  mercurial  purge  are  also  recommended.  Sodium 
bicarbonate  may  be  given  in  5]  doses,  in  Vichy  water, 
between  meals ;  or  any  of  the  simple  alkaline  mineral  waters 
may  be  given,  of  which  Vichy  is  perhaps  the  best.  Rectal 
injections  of  cold  water  certainly  do  good  in  diminishing 
the  jaundice.  From  i  to  2  quarts  of  water  should  be  slowly 
injected  into  the  rectum  once  a  day,  and  retained  as  long  as 
possible.  At  first  the  temperature  of  the  water  should  be 
60°  F.,  but  in  later  injections  the  temperature  of  the  water 
may  be  reduced  gradually,  so  that  finally  ice-water  may  be 
used.  Pruritus  is  to  be  treated  by  bathing  the  itching  parts 
with  a  solution  of  carbolic  acid  (i  :  200)  or  one  of  bichloride 
of  mercury  (gr.  j  :  5j) ;  or  a  saturated  solution  of  sodium 
bicarbonate  may  be  used.  In  some  cases  a  calomel  oint- 
ment affords  relief.  In  severe  cases  internal  remedies  may 
be  necessary,  as  phenacetine  or  sodium  bromide. 

CHOLELITHIASIS. 
Etiolog-y  and  Synonyms. — Gall-stones  occur  more  fre- 
quently in  women  (75  per  cent,  of  cases)  than  in  men,  and 
especially  in  women  between  thirty  and  sixty  years  of  age. 
Tight  lacing,  over-eating,  especially  of  saccharine  and 
starchy  food,  and  sedentary  modes   of  life  seem  to  act  as 


544        .V.I.VCIL    OF   THE  PRACTICE    OF  MEDICLXE. 

important  factors  in  their  causation.  The  patients  are 
usually  stout,  and  the  combination  of  fatty  liver  with  biliary 
calculi  is  exceedingly  common.  Of  women  with  gall-stones, 
90  per  cent,  have  borne  children.  Synonpns:  Gall-stones; 
Biliary  calculi. 

Pathology. — Biliary  calculi  are  in  almost  all  instances 
formed  within  the  gall-bladder,  but  in  rare  cases  they  may 
arise  in  the  small  ducts  within  the  liver.  Stones  found  in 
the  larger  ducts  do  not  originate  there,  but  become  impacted 
on  tiieir  way  to  the  intestine  along  the  duct.  Two  varieties 
of  biliary  calculi  are  found,  one  coi^isisting  of  inspissated 
bile,  and  the  second  comprising  calculi  proper. 

1.  Inspissated  bile  occurs  as  a  brown  or  greenish-black 
semi-solid  mass  composed  of  the  solid  constituents  of  bile 
with  the  admixture  of  mucus.  The  same  symptoms  may 
arise  from  inspissated  bile  as  from  the  regular  calculi. 

2.  The  regular  biliary  calculi  are  not  always  composed 
of  the  same  ingredients. 

{a)  Some  are  composed  of  cholesterin,  alone  or  with  bile- 
pigment. 

(/;)  Some  are  composed  of  cholesterin,  bile-pigment,  and 
the  salts  of  lime  and  magnesium.  These  two  are  the 
ordinary  varieties.  The  calculi  are  soft,  light  and  can  be 
cut  easily  with  a  knife. 

{c)  Rarely  the  calculus  consists  of  bile-pigment  alone  or 
of  calcium  carbonate  alone.  These  latter  varieties  form 
small  hard  gravel,  the  so-called  "  gall-sand."  There  is 
usually  a  central  nucleus,  which  may  consist  of  mucus  or 
of  bile-pigment. 

The  number  of  calculi  that  may  be  found  in  the  gall- 
bladder varies  up  to  several  thousand.  The  calculi  vary 
in  size  from  a  grain  of  sand  to  that  of  a  lemon  ;  the  greater 
their  number  the  smaller  they  are.  The  color  varies  from 
white  to  a  waxy  lemon  or  a  greenish-yellow,  according  to 
the  amount  of  pigment  they  contain.  More  rarely  they  are 
bronze-green  or  even  black.  The  purer  cholesterin-calculi 
are  nearly  white,  are  of  a  crystallized  structure,  and  readily 
cut  like  wax.    The  calculi  are  round,  irregular,  or  oblong,  or 


cn()  /,  /•:  I.  /  7  •///.  /  .sy.S'.  545 

they  may  be  polyhedral  and  faceted  by  mutual  pressure  and 
friction. 

The  exact  reason  for  the  formation  of  biliary  calculi  is  un- 
known. It  is  a  fact  that  cholesterin  is  precipitated  if  the  bile 
becomes  acid,  but  whether  this  precipitation  actually  occurs 
within  the  body  is  unknown.  It  is  supposed  that  cholesterin 
is  also  precipitated  whenever  there  exi.st  defects  in  the  sodium 
salts.  It  is  known  that  the  formation  of  calculi  is  favored 
by  any  cause  retarding  the  flow  of  bile  and  by  all  unhealthy 
conditions  of  the  bile-passages. 

Symptoms. — Gall-stones  give  rise  to  symptoms  in  three 
different  ways : 

I.  By  their  passage  through  the  ducts ;  2.  By  their  impac- 
tion in  the  ducts ;  3.  By  their  retention  within  the  gall- 
bladder. 

I,  Passage  tliroiigJi  the  Ducts. — Small  stones  may  pass 
from  the  gall-bladder  through  the  cystic  and  common  ducts 
without  symptoms,  or  there  may  result  slight  jaundice  and 
discomfort  in  the  region  of  the  liver.  Larger  calculi  en- 
gaging in  the  ducts  give  rise  to  the  symptoms  of  biliary  or 
hepatic  colic — pain,  vomiting,  fever,  jaundice,  and  slight 
enlargement  of  the  liver.  The  attack  is  sudden,  usually 
occurring  several  hours  after  a  heavy  meal  or  after  muscular 
exertion.  The  pain  starts  from  the  epigastrium  and  radiates 
through  to  the  back  and  upward,  so  that  it  may  be  felt  in 
the  right  shoulder.  Radiation  of  the  pain  downward  is  ex- 
ceedingly rare — a  point  of  differential  diagnosis  from  renal 
colic.  There  are  two  elements  to  the  pain — a  steady  grind- 
ing ache,  with  sharp  cutting  or  stabbing  paroxysms  of  un- 
bearable intensity.  During  the  paroxysms  of  pain  the  face 
is  pale,  the  body  is  bathed  in  perspiration,  and  attacks 
of  syncope  and  convulsions  are  not  infrequent.  Fatal 
syncope  or  collapse  has  occasionally  been  observed.  At 
the  onset  the  pain  may  be  relieved  by  pressure,  but  later 
tenderness  develops,  especially  over  the  gall-bladder.  Nau- 
sea and  vomiting  almost  regularly  occur  during  the  attack. 
The  vomited  matt-ers  contain  no  bile  if  the  common  duct  be 
obstructed,  but  in  the  vomita  biliar}-  calculi  may  be  found. 
Chills  are  common  at  the  onset  of  the  attack,  and  recur  at 
35 


546        MAXTAL    OF   THE    PRACTICE    OF  MEDICLXE. 

intervals  which,  in  protracted  cases,  may  be  of  such  regu- 
larity as  to  resemble  mahu-ial  fe\cr.  The  temperature  is 
temporarily  raised  during  the  attack  to  102°  or  104°  F.,  but 
if  the  attack  be  slight  and  of  short  duration  there  may  be  no 
fever.  In  protracted  cases,  especially  if  there  be  a  compli- 
cating inflammation  of  the  biliary  passages,  there  may  be 
an  intermittent  or  remittent  fever  resembling  that  of  malaria 
and  accompanied  b}-  repeated  rigors.  This  "  intermittent 
hepatic  fever"  also  occurs  with  impaction  of  the  stone  with- 
in the  common  bile-duct. 

The  pulse  during  an  attack  of  biliary  colic  is  often  slow,  but 
it  ma\-  be  rapid,  feeble,  or  irregular.  In  from  twelve  to 
twenty-four  hours  jaundice  appears,  with  the  regular  symp- 
toms of  the  obstructive  variety,  but  it  usually  disappears  in 
about  a  w^eek  after  the  close  of  the  attack.  Persistence  of 
the  jaundice  after  this  time  suggests  catarrhal  inflammation 
of  the  bile-ducts  (catarrhal  cholangitis)  or  impaction  of  the 
calculus  within  the  duct.  Jaundice  is  not,  however,  con- 
stant, as  it  does  not  appear  in  case  of  a  very  small  calculus 
within  the  common  bile-duct,  not  entirely  occluding  it,  or  in 
the  case  of  a  calculus  passing  the  cystic  duct.  Toward  the 
close  of  the  attack  the  liver  is  moderately  enlarged  and 
tender,  and  the   gall-bladder  maj^  be  felt  to  be  distended. 

The  attack  terminates  suddenly  with  the  dropping  of  the 
calculus  into  the  duodenum,  and  the  sharp  pain  ceases  at 
once,  leaving  a  dull  ache  which  may  persist  for  several 
days.  Sudden  cessation  of  pain  is  also  observed  in  cases 
in  which  a  calculus  engages  in  the  cystic  duct  and  then 
drops  back  again  into  the  gall-bladder. 

The  dtiration  of  an  attack  of  biliary  colic  varies  from 
several  hours  to  days.  Protracted  cases  are  usually  due  to 
the  merging  together  of  a  series  of  attacks.  Recurrences 
are  common,  because  the  biliary  calculi  usually  occur  in  the 
gall-bladder  in  great  numbers. 

The  diagnosis  of  cholelithiasis  is  rendered  positive  by 
finding  the  calculi  in  the  stools  or  in  the  vomited  matters. 
The  stools  should  be  tied  up  in  a  gauze  bag,  which  is  to  be 
attached  to  a  water-faucet  so  that  the  feculent  matter  may  be 
washed  through  the  meshes  of  the  gauze,  leaving  the  cal- 


CHOI.  /•:  L  J  7  'HI A  SIS.  547 

culi  in  the  bag.  A  faceted  appearance  of  a  calculus  implies 
that  it  is  one  of  many. 

The  prognosis  for  the  attack  itself  is  good,  although  fatal 
syncope,  collapse,  and  rupture  of  the  duct  have  occurred. 
Cerebral  hemorrhage  has  repeatedly  been  observed  during 
an  attack. 

2.  Impaction  in  the  Ducts. — The  symptoms  of  impaction 
follow  those  cases  of  biliary  colic  in  which  the  pain  gradu- 
ally ceases,  leaving  a  considerable  dull  aching  feeling  ;  they 
differ' according  to  whether  the  cystic  or  the  common  bile- 
duct  be  the  seat  of  the  impaction, 

(a)  Impaction  in  the  Cystic  Duct. — There  is  usually  no 
jaundice,  but  the  effects  of  the  impaction  fall  upon  the  gall- 
bladder, which  may  undergo  the  following  changes : 

(i)  The  gall-bladder  becomes  distended  with  thin,  color- 
less, mucoid  contents — the  so-called  "  dropsy  of  the  gall- 
bladder," or  "  hydrops  vesicae  felleae."  A  large  globular 
tumor  is  thus  formed,  projecting  from  the  under  surface  of 
the  liver  to  the  right  of  the  median  line.  The  distended 
gall-bladder  may  reach  such  dimensions  as  to  extend  to  the 
navel  or  even  to  the  level  of  the  anterior  spines.  In  some 
cases  the  gall-bladder  becomes  distended  without  projecting 
beyond  the  lower  border  of  the  liver. 

(2)  Acute  phlegmonous  cholecystitis  may  occur,  with 
perforation  and  fatal  peritonitis,  but  the  condition  is  one  of 
great  rarity. 

(3)  Suppurative  cholecystitis,  or  empyema  of  the  gall- 
bladder, is  of  not  infrequent  occurrence.  The  bladder  is 
distended  by  pus  and  is  the  source  of  pain  and  tenderness. 
Septic  symptoms  are  those  of  a  localized  abscess.  Perfora- 
tion may  occur  into  the  peritoneum,  into  hollow  viscera,  or 
through  the  abdominal  wall,  forming  biliary  fistulae;  or 
there  may  be  formed  an  acute  circumscribed  peritoneal 
abscess.  Calcification  of  the  gall-bladder  or  lime-incrusta- 
tions of  the  mucosa  may  follow  the  drainage  of  the  em- 
pyema. 

(4)  Atrophy  of  the  gall-bladder  may  result  in  its  trans- 
formation into  a  little  ball  of  connective  tissue. 

[b)  Impaction  within  the  common  bile-duct  causes  persistent 


54^        .V.IXC.I/.    OF   THE    PRACriCK    OF  MFDICIXE. 

obstructive  jaundice.  The  secondary  results  of  such  an 
impaction  fall  upon  the  bile-passages  and  the  liver.  The 
gall-bladder  is  seldom  involved. 

(1)  ItifJammatiofi  of  the  Bi/iarv  Passages. — There  may  be 
a  catan'Jial  c/iolangitis.  The  biliar\'  ducts  are  dilated  and 
filled  with  a  colorless  mucoid  fluid.  The  symptoms  are 
those  of  jaundice  with  "  intermittent  hepatic  fever."  Chills 
occur,  with  elevations  in  temperature  to  103°  or  104°  F., 
the  fall  of  the  fever  being  accompanied  by  sweating.  These 
ague-like  paroxysms  may  occur  with  such  periodicity  as  to 
be  mistaken  for  malaria,  and  they  may  occur  at  intervals  for 
months  or  even  for  years.  With  each  paroxysm  the  jaun- 
dice deepens,  and  pain  over  the  liver  and  gastric  disturb- 
ances are  observed.  In  the  intervals  between  the  paroxysms 
the  patient  is  deeply  jaundiced,  but  the  temperature  is  nor- 
mal and  there  is  rarely  any  depreciation  in  the  general 
health.  The  exact  cause  for  this  hepatic  fever  is  not 
known. 

(2)  Siipptirative  cholangitis  is  attended  b\'  suppuration 
extending  along  the  biliary  passages  and  frequently  involv- 
ing the  gall-bladder.  Suppuration  may  extend  to  the  liver 
surrounding  the  ducts,  so  that  the  organ  is  penetrated  by 
long,  branching  abscess-cavities.  The  liver  becomes  en- 
larged and  tender,  symptoms  of  .septicaemia  or  of  pyaemia 
develop,  and  the  disease  runs  a  short  and  fatal  course. 

The  effect  on  the  liver  o^  such  an  impaction  in  the  common 
duct  is  to  cause  its  enlargement.  The  liver  is  rendered 
firmer  by  deposits  of  connective  tissue  along  the  course  of 
the  biliary  ducts,  and  the  lesions  of  biliary  cirrhosis  may 
thus  ultimately  develop. 

When  a  calculus  becomes  impacted  in  either  the  cystic 
or  the  hepatic  duct,  it  may  there  remain  indefinitely,  or  it 
may  progress  along  the  duct  by  starts,  so  that  finally  the 
passage  to  the  duodenum  is  accomplished.  This  favorable 
outcome  of  the  impaction  is  more  common  if  several  calculi 
are  wedged  together,  so  that  at  any  time  the  wedge  may  be 
broken  up  and  the  individual  calculi  be  passed  without 
difficult}'. 

Perforation  of  the   duct   is  of  common  occurrence,  and 


cuo  f.  /','  1. 1 J  ///A  s/s.  549 

biliary  fistulae  thus  formed  may  open  through  the  abdominal 
wall,  into  the  abdominal  cavity,  into  the  duodenum  or  the 
colon,  more  rarely  into  the  gall-bladder,  the  substance  of 
the  liver,  the  lungs,  the  stomach,  the  small  intestine,  or  the 
pelvis  of  the  kidney.  The  calculi  may  be  discharged 
through  the  fistulous  opening,  frequently  in  great  num- 
bers, and  spontaneous  cure  may  result.  Obstruction  to  the 
bowels  may  result  from  the  perforation  of  large  solitary 
gall-stones  into  the  duodenum.  In  other  cases  perforation 
cA  the  duct  leads  to  the  formation  of  a  circumscribed  peri- 
toneal abscess. 

In  some  instances  a  calculus  may  pass  into  the  common 
duct  and  remain  there  without  actually  obstructing  the  duct. 
A  slow  increase  in  the  size  of  the  calculus  is  compensated 
by  a  gradual  dilatation  of  the  duct. 

3.  Retention  of  calculi  zvithin  the  gall-bladder  is  of  such 
common  occurrence  as  to  be  found  in  25  per  cent,  of  all 
autopsies  made  on  women  over  sixty  years  of  age.  In  many 
cases  this  condition  gives  absolutely  no  symptoms,  but  post- 
mortem examination  may  show  the  gall-bladder  nearly 
empty  of  bile  and  contracted  upon  the  calculi,  with  oblitera- 
tion of  the  cystic  duct  by  a  calculus.  In  the  majority  of  cases, 
however,  calculi  from  time  to  time  enter  the  cystic  duct  and 
pass  to  the  duodenum  or  drop  back  into  the  gall-bladder. 
In  either  case  symptoms  of  biliary  colic  are  observed,  but 
in  the  latter  instance  jaundice  does  not  occur  and  the  pain 
may  be  of  short  duration.  Calculi  remaining  in  the  gall- 
bladder may  excite  a  catarrhal  or  suppurative  inflammation 
of  its  wall.  Catarrhal  cholecystitis  is  attended  by  a  globu- 
lar enlargement  of  the  gall-bladder,  with  pain  and  tender- 
ness. The  symptoms  of  empyema  of  the  gall-bladder  have 
already  been  described. 

Treatment  of  Cholelithiasis. — i.  During  the  attack  of 
biliary  colic  the  indications  are  to  relieve  pain  and  spasm. 
A  hot  bath  is  of  comfort,  and  until  the  bath  can  be  pre- 
pared hot  applications  over  the  liver  are  of  service.  Hypo- 
dermic injections  of  morphine  (gr.  1)  with  atropine  (gr.  j-l^) 
are  to  be  given,  and  in  severe  cases  whiffs  of  chloroform 
may  be  necessary  until  the  patient  is  under  the  effect  of  the 


5  50        M.lXr.iL    OF   THE   PKACTICK    OF  MFDICIXE. 

opiate.  It  should  be  remembered  that  the  pain  may  cease 
suddenly,  and,  tolerance  for  the  morphine  being  thus  les- 
sened, toxic  effects  may  result  if  too  large  doses  have  been 
given.  Copious  draughts  of  hot  water  containing  sodium 
bicarbonate  (.^j  :  Oj)  exert  a  sedative  effect,  provided  that 
vomiting  is  not  induced. 

2.  If  the  ducts  be  occluded,  various  methods  have  been 
recommended  to  dissolve  the  calculus  or  to  dislodge  it 
mechanicalh-.  Olive  oil  in  large  doses  has  been  recom- 
mended, but  it  is  useless,  the  alleged  calculi  passed  after  its 
administration  having  been  proved  to  be  lumps  of  fatty 
concretions.  Durande's  formula,  consisting  of  3  parts  of 
ether  and  2  parts  of  turpentine,  may  be  given  in  from  15- to 
20-drop  doses  three  times  a  day.  It  is  much  used  by 
European  physicians,  but  is  of  doubtful  utility.  Chloroform 
internally  and  salicylate  of  soda  have  been  recommended, 
but  no  drug  thus  far  has  proved  to  be  of  any  value  in  dis- 
solving the  stone. 

If  the  impaction  be  accompanied  by  inflammatory  symp- 
toms, the  stone  may  be  removed  surgically,  or  the  duct 
may  be  exposed  and  the  calculus  be  broken  up  without 
incising  the  wall  of  the  duct. 

3.  If  empyema  of  the  gall-bladder  occur,  the  condition 
demands  surgical  treatment.  For  cases  of  repeated  attacks 
of  gall-stone  colic,  with  accumulations  of  calculi  in  an 
inflamed  gall-bladder,  the  operation  of  cholecystotomy,  or 
opening  the  gall-bladder  and  removing  the  stones,  has  been 
remarkably  successful. 

Dropsy  of  the  gall-bladder  may  be  treated  by  repeated 
aspirations. 

To  prevent  the  formation  of  gall-stones,  highly  seasoned 
and  indigestible  food  should  be  avoided,  and  total  absti- 
nence from  alcohol  should  be  insisted  upon.  The  bowels 
should  be  kept  freely  open,  and  abundant  systematic  exer- 
cise should  be  enforced.  Hot  morning  draughts  of  the 
alkaline  mineral  waters  are  of  service,  or  sodium  phosphate 
in  dram  doses  may  be  given  in  a  tumblerful  of  hot  water 
before  breakfast. 


DISEASES   OF   THE   BLOOD-VESSELS    OF    77/E   LIVE  A'.   55 1 

CANCER    OF    THE    GALL-DUCTS. 

Cancer  of  the  liver  starting  from  the  endotheHum  of  the 
bihary  passages  has  already  been  described. 

The  common  bile-duct  in  rare  instances  is  the  seat  of  the 
primary  cancer.  The  symptoms  are  those  of  chronic 
obstructive  jaundice  and  of  cancerous  cachexia.  The  diag- 
nosis is  seldom,  if  ever,  made  during  life,  and  no  treatment 
is  available  except  that  for  the  relief  of  pain. 

Cancer  of  the  gall-bladder  is  also  exceedingly  rare.  The 
tumor  reaches  considerable  size,  usually  that  of  a  child's 
head. 

Secondary  nodules  in  the  liver  occur  by  direct  extension 
or  by  metastasis  through  the  portal  vein.  The  symptoms 
are  those  of  an  enlarged,  tender,  and  painful  tumor  in  the 
location  of  the  gall-bladder,  of  secondary  growths  in  the 
liver,  and  of  cancerous  cachexia.  The  early  symptoms 
resemble  those  of  gall-stones.  Treatment  is  palliative, 
unless  an  early  diagnosis  renders  it  possible  to  remove  the 
gall-bladder  by  operation. 

DISEASES  OP  THE  BLOOD-VESSELS  OP  THE 
LIVER. 

Hepatic  Artery. — Aneurysm  of  the  hepatic  artery  has 
been  observed  in  a  few  cases.  There  may  be  pressure  on 
the  portal  vein  or  on  the  bile-ducts. 

Hepatic  Vein. — Affections  of  the  hepatic  vein  are  almost 
unknown. 

Portal  Veins. —  i.  Chronic  portal  obstruction  may  arise 
from  chronic  diseases  of  the  heart  and  the  lungs  and  from 
tumors  of  the  mediastinum  pressing  upon  the  vena  cava. 
The  portal  obstruction  thus  caused  is  accompanied  by 
oedema  of  the  lower  extremities  and  by  congestion  of  the 
kidney. 

Local  causes  for  portal  obstruction  are  cirrhosis,  throm- 
bosis, and  pressure  on  the  vein  by  tumors  in  the  liver  or  in 
its  vicinity.  The  vein  may  be  compressed  by  proliferative 
peritonitis  involving  the  grastro-hepatic  omentum. 

The  syniptovis  and  treatment  of  chronic  portal  obstruction 


55-        M.IXL'.U.    OF   THE   PRACTICE    OF  MFJ^ICLXF. 

have  been  tlcscribetl  at  length   in   the  consideration  of  Cir- 
rhosis of  the  Liver. 

2.  Thrombosis ;  Adiicsive  Pyleplilcbitis. — Primary  throm- 
bosis of  the  portal  vein  may  occur  as  a  terminal  event  in 
dying  patients,  but  it  is  of  no  practical  importance.  Sec- 
ondary thrombosis  is  regularly  due  to  pressure  upon  the 
portal  vein  or  upon  one  of  its  branches. 

Pathology. — The  vein  is  filled  with  a  recent  clot;  later  the 
thrombus  becomes  paler  and  harder,  and  ma)-  ultimately  be 
converted  to  connective  tissue. 

The  symptoms  are  those  of  sudden  portal  obstruction. 
The  abdominal  veins  become  distended ;  the  spleen  is  en- 
larged ;  vomiting,  h?ematemesis,  diarrhoea,  occasionally  with 
bloody  stools,  and  rapidly  forming  ascites  comprise  the 
prominent  symptoms.  In  no  other  disease  are  tliese  symp- 
toms of  portal  obstruction  so  rapidly  developed. 

If  the  portal  vein  itself  or  one  of  its  larger  branches  be 
occluded,  an  efficient  collateral  circulation  is  impossible. 
Death  results  in  a  few  days  from  prostration  and  heart  fail- 
ure, which  are  added  to  the  above-mentioned  symptoms. 
If  the  collateral  circulation  can  be  established,  a  certain 
amount  of  improvement  results,  and  the  patient  may  live 
for  years  with  indefinite  symptoms  of  moderate  portal  stasis  ; 
but  death  finally  results  from  emaciation,  from  exhaustion, 
or  from  hemorrhages. 

The  prognosis  of  thrombosis  of  the  larger  branches  of  the 
portal  vein  is  always  bad.  If  a  smaller  branch  be  occluded, 
the  prognosis  depends  upon  the  establishment  and  mainten- 
ance of  satisfactory  collateral  circulation. 

The  treatment  is  that  of  portal  obstruction  by  tapping, 
diuretics,  and  cathartics. 

3.  Septic  Thrombosis;  Suppurative  Pylephlebitis. — The 
thrombus  is  not  due  to  mechanical  pressure,  but  is  second- 
ary to  a  septic  inflammation  of  the  wall  of  the  vein.  Infec- 
tion is  caused  by  intestinal  ulceration,  by  abdominal  ab- 
scesses, or  by  sharp  foreign  bodies,  as  fish-bones,  which 
penetrate  the  wall  of  the  intestine  and  infect  a  branch  of  the 
portal  vein.     In  new-born  children  the  condition  may  arise 


DISEASES   OE   77/E   PANCREAS.  553 

from  sepsis  entering  through  the  navel  and  infecting  the 
clot  in  the  umbihcal  vein. 

Pathology. — By  the  influence  of  bacteria  the  clot  softens 
and  breaks  down  to  form  a  puriform  mass.  Septic  emboli, 
entering  the  liver,  give  rise  to  multiple  abscesses,  and  even 
to  general  pyjemia. 

The  symptoms  are  those  (i)  of  portal  obstruction,  (2)  of 
multiple  abscesses  in  the  liver,  and  (3)  of  pyaemia  or  septi- 
caemia. 

Prognosis. — The  disease  is  invariably  fatal,  usually  within 
two  weeks. 

The  treatment  is  symptomatic.  Operative  interference  is, 
of  course,  impossible. 


6.  DISEASES  OF  THE  PANCREAS. 

HEMORRHAGE. 

Hemorrhage  into  the  pancreas  is  of  rare  occurrence.  The 
subjects  have  usually  been  males  of  adult  life.  Injuries  and 
alcoholism  seem  to  bear  some  causative  relation  to  the  dis- 
ease, but  the  precise  causation  is  unknown. 

Pathology. — Hemorrhagic  infiltration  is  found  not  only 
in  the  substance  of  the  pancreas,  but  also  in  the  subperi- 
toneal tissue  in  its  vicinity. 

Symptoms. — There  is  suddenly  developed  intense  pain, 
referred  to  the  upper  part  of  the  abdomen ;  nausea,  vomit- 
ing, and  abdominal  tenderness  rapidly  follow.  The  patient 
becomes  anxious,  restless,  and  passes  into  a  fatal  collapse. 
In  the  rapidly  fatal  cases  death  may  result  in  from  half  an 
hour  to  two  hours.  In  less  severe  cases  the  symptoms 
merge  into  those  of  hemorrhagic  pancreatitis. 

Prognosis. — Theoretically  it  is  possible  for  recovery  to 
follow  small  hemorrhages,  but  practically  the  disease  is 
almost  certainly  fatal. 

Treatment  is  directed  toward  the  pain  and  the  collapse. 

ACUTE    HEMORRHAGIC   PANCREATITIS. 
Etiology. — The  subjects  of  pancreatitis  are  usually  males 
in  adult  life.     The  majority  of  the  reported  cases  have  been 


554      J/.i.vc'.-i/,  OF  THE  practice  oe  medicine. 

preceded  by  hemorrhage  into  the  pancreas,  by  alcohoh'sm, 
by  injury  to  the  abdomen,  or  by  repeated  attacks  of  gastro- 
duodenitis,  but  the  precise  causation  of  the  disease  is 
unknown. 

Pathology. — The  pancreas  is  enlarged  and  is  infiltrated 
with  blood.  The  color  of  the  gland  is  mottled  red  and 
yellow  and  dead  white.  The  latter  color  is  due  to  areas  of 
"  fat-necrosis  "  of  Balser.^  The  same  lesions  may  also  be 
found  in  the  root  of  the  mesentery,  in  the  mesocolon 
and  the  omentum,  and  in  the  retroperitoneal  tissues  in  the 
vicinity  of  the  pancreas.  If  the  patient  survive  long  enough, 
gangrenous  pancreatitis  may  develop. 

The  tallow-like  appearance  of  the  areas  of  fat-necrosis  is 
due  to  the  crystallization  of  fat,  as  the  area  is  found  to  con- 
sist of  stearin,  alone  or  combined  with  lime-salts.  The 
crystallization  is  supposed  to  be  due  to  contact  with  the 
pancreatic  secretion.  In  the  areas  of  fat-necrosis  various 
bacteria  have  been  found,  the  most  prominent  being  the 
bacillus  coli   communis. 

The  symptoms  begin  suddenly  with  an  intensely  violent 
pain,  usually  referred  to  the  upper  abdominal  region,  but 
which  may  be  more  general  than  this.  Vomiting  is  fre- 
quent and  usually  incessant.  The  vomited  matters  are 
bilious  and  may  contain  blood.  The  temperature  may  be 
normal,  subnormal,  or  slightly  elevated.  The  bowels  are 
usually  constipated.  The  abdomen  becomes  tympanitic 
and  tender.  Collapse-symptoms  rapidly  supervene,  and 
death  usually  results  from  the  second  to  the  fourth  day. 
Should  the  patient  survive,  the  symptoms  of  gangrenous 
pancreatitis   usually  appear. 

The  diagnosis  from  intestinal  obstruction  and  from  per- 
forative peritonitis  cannot  be  made  with  any  certainty. 

Prognosis. — The  disease  is  almost  certainly  fatal,  although 
one  case  of  recovery  has  been  reported  by  Osier. 

The  treatment  is  that  of  the  pain  and  the  collapse. 

^  Disseminated  areas  of  fat-necrosis  may  in  rare  instances  be  scattered 
throughout  the  abdomen,  even  in  cases  in  vvhicii  the  pancreas  is  found  to  be 
normal. 


SUPPURATIVE   PANCREATI'JIS.  555 

GANGRENOUS   PANCREATITIS. 

According  to  Fitz,  hemorrhagic  pancreatitis  not  ter- 
minating fatally  or  in  improvement  within  a  week  usu- 
ally results  in  gangrenous  pancreatitis.  The  pancreas  is 
converted  to  a  gangrenous  mass  lying  in  a  meshwork 
infiltrated  with  green  offensive  fluid  ;  or  the  sloughing  mass 
may  lie  in  the  lesser  omental  cavity,  attached  only  by  a  few 
loose  threads  to  its  walls,  and  may  be  discharged  through 
the  bowels  as  a  slough.  In  rare  cases  spontaneous  cure 
has  thus  resulted.  The  omental  cavity  contains  an  ichorous 
fluid  or  pus,  and  general  infection  of  the  peritoneum  may 
occur.  Disseminated  areas  of  fat-necrosis  are  usually  pres- 
ent, and  there  may  be  suppurative  pylephlebitis,  pericarditis, 
or  pleurisy. 

Symptoms. — The  disease  begins  as  a  hemorrhagic 
pancreatitis.  Symptoms  of  peritonitis  supervene,  usually 
localized  in  the  upper  portion  of  the  abdomen,  correspond- 
ing to  the  omental  cavity.    Collapse  precedes  the  fatal  issue. 

The  duration  of  the  disease  is  from  ten  to  twenty  days. 

The  prognosis  is  bad,  with  the  exception  of  the  very  rare 
cases  in  which  the  slough  is  passed  by  the  bowel. 

The  treatment  is  that  of  a  circumscribed  peritonitis,  and 
is  distinctly  surgical. 

SUPPURATIVE    PANCREATITIS. 

Etiology. — The  method  of  infection  is  unknown. 

Pathology. — The  pancreas  may  be  studded  with  small 
abscesses  or  may  be  converted  to  a  cyst  filled  with  pus.  A 
diffuse  peritonitis  may  result,  or  the  abscess  may  rupture 
into  the  lesser  omental  cavity  or  into  the  duodenum.  Sup- 
purative pylephlebitis  and  abscesses  in  the  liver  are  not 
infrequent.     Areas  of  fat-necrosis  are  but  rarely  observed. 

Symptoms. — Epigastric  pain,  vomiting,  and  prostration 
mark  the  onset  of  the  disease.  Septic  symptoms  develop, 
abdominal  distention  and  tenderness  become  marked,  and 
death  results  in  from  two  to  four  weeks.  Other  cases  run 
a  more  chronic  course  extending  over  weeks  or  months. 
Fever  is  slight  or  altogether  absent.     There   is  but  little 


556        J/J Xr.-i /.    OF  THE   rKACllCE    OF  MFDICINE. 

pain,  altlioiii:^h  tondcrn-^ss  is  elicited  in  the  rei:^ion  of  the 
pancreas.  The  patient  becomes  weak  and  thin,  and  dies 
exhausted  in   from  six  to  twelve  montlis. 

The  prognosis  is  invariabl}-  fatal. 

The  treatment  is  surgical. 

CHRONIC    PANCREATITIS. 

Etiolog-y. — This  condition  may  be  due  to  congenital 
syphilis,  but,  with  this  exception,  little  is  known  as  to  the 
etiolog)-  of  the  disease. 

Patholog-y. — The  pancreas  may  be  enlarged  or  diminished 
in  size.  There  is  a  great  increase  in  the  interstitial  connec- 
tive tissue,  and  the  glandular  structure  ma\'  become  changed 
or  atrophied. 

Symptoms. — There  are  no  characteristic  symptoms. 
There  are  commonly  present  digestive  disturbances  resem- 
bling those  of  chronic  gastro-enteritis.  The  stools  may  be 
fatty.  Jaundice  is  present  in  some  cases,  and  is  due  to  the 
pressure  of  the  enlarged  pancreas  upon  the  common  duct. 
There  may  be  considerable  epigastric  pain  and  tenderness, 
and  in  some  cases  a  sense  of  resistance  can  be  appreci- 
ated over  the  pancreas.  Emaciation  and  debility  become 
progressive.  In  some  cases  glycosuria  has  been  observed, 
and  the  disease  may  run  the  course  of  a  severe  diabetes. 
Ascites  may  develop  in  advanced  cases. 

The  disease  is  chronic,  but,  from  the  insidious  character 
of  the  symptoms  presented,  the  precise  duration  of  the 
disease  cannot  be  determined. 

The  prognosis  is  grave,  but  not  hopeless. 

The  treatment  is  to  be  supporting.  The  general  nutri- 
tion of  the  patient  should  be  improved  in  every  possible 
way,  and  pancreatin  or  minced  pancreas  may  be  given,  as 
indicated  in  all  cases  of  diminished  pancreatic  digestion. 

PANCREATIC   CYSTS. 
Retention-cysts  may  arise    from    the    occlusion  of  Wir- 
sung's  duct  by  biliary  or  pancreatic  calculi.    The  latter  con- 
sist mainl}'  of  carbonate  of  lime.     The  duct  may  be  obliter- 
ated by  pressure  from  without  or  by  cicatricial  contraction. 


CANCKR    OF   17 IK    PANCREAS.  SS7 

In  rare  cases  cystomata  may  occur  and  may  merge  into 
malignancy. 

Pathology. — The  cysts,  which  may  be  single  or  multiple, 
are  filled  with  an  alkaline  grayish  fluid  which  emulsifies  fats, 
converts  starch  into  glucose,  and,  more  rarely,  digests  albu- 
min. These  characteristics,  however,  are  not  peculiar  to 
pancreatic  cysts,  and  the  older  the  cyst  is,  the  less  likely  is 
the  fluid  to  present  these  reactions.  Hemorrhages  into  the 
cyst  are  common,  so  that  the  fluid  becomes  bloody  or  of  a 
brown  or  chocolate  color. 

The  symptoms  are  chiefly  those  of  an  abdominal  tumor, 
which  is  of  globular  form,  resistant  and  smooth,  and  in  some 
cases  fluctuating.  The  tumor  first  presents  itself  in  the 
epigastrium  or  in  the  left  hypochondrium,  but  may  extend 
to  fill  the  entire  abdominal  cavity.  There  may  be  a  decep- 
tive pulsation  which  is  transmitted  from  the  aorta.  Pain 
is  inconstant.  There  may  be  symptoms  of  pressure  on  the 
portal  vein  and  on  the  bile-ducts,  and  cases  of  fatal  rupture 
have  occurred. 

The  growth  of  the  cyst  may  be  apparent  in  three  weeks, 
but  usually  the  course  is  chronic  and  extends  over  months 
and  years.  A  sudden  enlargement  is  suggestive  of  hemor- 
rhage within  the  cyst. 

The  prognosis  is  generally  good. 

The  treatment  is  sursfical. 


CANCER   OF    THE    PANCREAS. 

Etiology. — The  growth  is  more  apt  to  occur  in  men  than 
in  women,  and  in  those  past  thirty  years  of  age. 

Pathology. — Cancer  of  the  pancreas  may  be  primary  or 
secondary.  Scirrhus  is  the  most  frequent  variety.  The 
growth  may  be  limited  to  the  pancreas  or  may  spread  to  the 
stomach,  the  intestines,  the  peritoneum,  or  the  liver. 

The  symptoms  are  often  obscure.  Dyspeptic  symptoms, 
loss  of  flesh  and  of  strength,  and  cancerous  cachexia  are 
constant  and  progressive.  When  the  head  of  the  pancreas 
is  involved  (in  one-third  of  all  the  cases)  jaundice  invariably 
results.     Ascites  results  if  the  portal  vein  be  pressed  upon. 


538        MAXrAL    OF   THE   PRACTICE    OF  MEDICLXE. 

The  patient  may  at  any  time  vomit  blood,  from  ulceration  of 
the  duodenum.  The  stools  may  be  fatty ;  usually  they  contain 
undigested  food.  Glycosuria  may  be  observed.  Epigastric 
pain  and  tenderness  are  almost  invariably  present.  A  tumor 
is  apparent  in  half  the  cases,  and  is  of  an  irregular,  more  or 
less  rounded  form.  The  tumor  is  immovable,  and  may 
transmit  a  pulsation  from  the  underlj'ing  aorta,  so  that 
in  doubtful  cases  the  patient  should  be  examined  in  the 
knee-chest  position. 

The  duration  of  the  disease  is  rarely  over  one  year,  and 
the  result  is  invariably  fatal. 

The  treatment  is  entirely  sjniptomatic. 

Of  other  varieties  of  new  growths  of  the  pancreas,  sar- 
coma, cystic  epithelioma,  and  syphiloma  have  been  described, 
but  they  are  all  exceedingly  rare. 


V.  DISEASES  OF  THE  KE)NEYS. 


CONGENITAL    MALFORMATIONS    OF    THE 
KIDNEYS. 

There  may  be  atrophy  or  congenital  absence  of  one  kid- 
ney, the  other  organ  being  considerably  enlarged.  Both 
kidneys  may  be  fused  into  one  horseshoe-shaped  kidney,  or 
into  an  irregular  mass  which  may  be  displaced  downward 
into  the  pelvis  or  either  iliac  fossa,  or  may  lie  in  the  middle 
line  of  the  abdomen.  These  malformations  must  be  remem- 
bered in  operating  on  the  kidney.  Cases  are  on  record  in 
which  calculi  have  been  impacted  in  the  ureter  of  a  horse- 
shoe kidney,  with  complete  anuria  and  death. 

MOVABLE   KIDNEY.- 

Synonyms. — Floating  kidney;  Palpable  kidney;  Ren 
mobilis ;  Nephroptosis. 

The  kidney  is  retained  in  place  by  its  fatty  capsule,  by 
the  peritoneum,  and  by  the  renal  vessels.  Under  certain 
circumstances  it  becomes  movable,  pushing  the  peritoneum 
before  it.  In  rare  cases  it  may  be  invested  with  peritoneum, 
which  is  reflected  at  the  hilum  to  form  a  mesonephron  ;  to 
such  a  condition  the  term  "  floating  kidney  "  is  limited  by 
some.  The  right  kidney  alone  is  affected  in  76  per  cent,  of 
all  cases,  both  kidneys  in  13  per  cent,  and  the  left  kidney 
alone  in   1 1   per  cent. 

Etiolog-y. — Congenital  cases  are  rare.  As  an  acquired  dis- 
ease movable  kidney  is  more  common  in  women  than  in  men, 
in  the  proportion  of  9:  i.  It  is  most  common  in  multiparae, 
in  the  laboring-classes,  and  after  thirty-five  years  of  age.  It 
may  be  due  to  congenital  laxity  of  the  peritoneal  attach- 
ments, to  the  laxity  of  the  abdominal  wall  due  to  repeated 
pregnancies,  to  tight  lacing,  to  severe  bodih^  labor,  or  to 
absorption  of  the  fatty  capsule.    The  kidney  may,  moreover, 

559 


560        .U.IXL.IL    OF   THE  PKACIICE    OF  MEDICIXE. 

be  displaced  downward  b}-  tumors.  The  term  "  enterop- 
tosis"  has  been  applied  to  cases  of  prolapse  of  the  abdomi- 
nal organs,  especially  of  the  transverse  colon,  with  movable 
kidney;  and  frequcnth'  with  dilatation  of  the  stomach. 

Symptoms. — In  the  \ast  majority  of  cases  there  are  no 
s\-mptoms  referable  to  the  trouble,  except  that,  should  the 
tumor  be  accidentally  discovered  by  the  patient,  nervous 
symptoms  due  to  alarm  and  apprehension  ma\'  result.  In 
other  cases  there  appear  neurasthenic  s}'mptoms  even  to  the 
verge  of  hysteria,  with  nervous  indigestion,  and  in  many 
instances  accompanied  by  pain.  This  pain  may  be  referred 
to  the  back,  on  the  side  of  the  movable  kidney,  and  may 
radiate  around  the  ribs,  downward  to  the  thigh,  or  forward 
to  the  epigastrium.  The  pain  is  aggravated  or  induced  by 
exertion,  jolting,  or  the  erect  posture.  In  some  instances 
there  may  be  merely  a  dragging  feeling  or  a  sense  of  weight 
or  pressure.     The  pain  may  be  the  only  symptom. 

In  "floating  kidney"  there  maybe,  in  rare  instances, 
attacks  characterized  by  mtense  abdominal  pain,  chills, 
vomiting,  and  s\'mptoms  of  fever  and  collapse.  The  urine 
is  usually  diminished,  high-colored,  and  contains  an  excess 
of  uric  acid  or  of  oxalate  of  lime.  These  "  incarceration- 
s\-mptoms  "  are  thought  to  be  due  to  kinks  or  twists  in  the 
ureter  or  the  renal  vessels,  but  observations  on  this  point 
are  not  definite.  Care  should  be  taken  not  to  mistake  these 
attacks  for  those  of  acute  peritonitis,  renal  calculus,  or 
appendicitis.  Twisting  of  the  ureter  may  give  rise  to  tem- 
porary or  permanent  h)'dronephrosis,  which  may  also  be 
intermittent.  P\-elitis  may  also  result.  A  floating  kidney 
may  press  on  the  bile-duct  and  cause  jaundice,  or  on  the 
vena  cava  and  cause  oedema  of  the  legs. 

Physical  Examination. — The  patient  being  placed  in  the 
dorsal  position  with  the  knees  drawn  up  and  the  abdominal 
wall  relaxed,  one  hand  is  placed  behind  in  the  lumbar  region 
while  the  other  hand  is  placed  in  the  hypochondrium  under 
the  margins  of  the  ribs.  Bimanual  palpation  reveals  a  solid 
smooth  tumor,  of  the  size  and  shape  of  the  kidney,  which 
is  freely  movable.  It  is  not  tender  except  on  firm  pressure. 
The  detection  of  a  movable  kidney  of  the  right  side  may  be 


ANOAfALrKS    OJ'    'J'JIJC    Ch'/MARY  SKCR /■//•/ON.         561 

aided  by  asking  the  patient  to  take  a  long  breath,  so  as  to 
depress  the  Hver  and  thus  push  the  kidney  down  into  reach. 
There  is  often  an  advantage  in  getting  the  patient  to  assume 
the  knee-chest  position.  At  times  a  number  of  examina- 
tions are  requisite  before  a  positive  diagnosis  can  be  made. 

Treatment  is  indicated  only  when  the  displacement  of  the 
kidney  gives  rise  to  symptoms.  The  simplest  form  of  treat- 
ment is  to  put  the  patient  in  bed  for  a  month  and  then  let 
him  go  about  with  a  binder  and  a  pad  to  keep  the  kidney 
in  place.  This  plan  will  work  well  in  some  cases,  but  not 
in  others.  In  severe  cases  not  relieved  by  this  procedure 
surgical  interference  may  be  necessary,  the  kidney  either 
being  removed  or  being  stitched  in  its  proper  place  by 
sutures. 

ANOMALIES   OP    THE    URINARY   SECRETION. 

Albuminuria. 

Both  serum-albumin  and  globulin  can  escape  through 
the  capillaries  of  the  Malpighian  tuft  and  appear  in  the  urine. 
In  practice  it  is  not  necessary  to  discriminate  between  these 
forms,  and  they  are  both  commonly  described  by  the  term 
"  albumin."  Albumin  in  the  urine  was  formerly  considered 
as  a  positive  proof  of  organic  disease  of  the  kidney,  but  it  is 
now  known  that  not  only  may  advanced  nephritis  exist 
without  albumin,  but  that  albumin  may  appear  in  cases 
without  kidney-lesion,  although  in  these  cases  it  is  supposed 
that  there  must  be  some  failure  in  the  nutrition  of  the  epi- 
thelium of  the  capillaries  of  the  tuft,  allowing  of  the  escape 
of  albumin  through  them.  Three  distinct  forms  of  albu- 
minuria are  recognized : 

I.  Spurious  Albiwihiuria. — Urine  admixed  with  blood  (as 
in  hematuria  or  in  haemoglobinuria)  or  with  pus  will  give 
the  reaction  for  albumin  in  proportion  to  the  amount  of 
blood  or  of  pus  present.     Tube-casts  do  not  appear. 

2.  Functional  or  Physiological  Albuminuria. — {a)  Albumin- 
uria may  follow  severe  muscular  exertion,  sustained  mental 
effort,  excessive  albuminous  food,  violent  emotions,  or  cold 


562        .U.l.Vr.lL    OF   THE  rKACTICE    OF  MFDICIXF. 

bathing.  A  few  li\-alinc  casts  nia\-  be  present,  especially 
after  exertion. 

(/;)  Hicniic  CcJKSfS. — Albuminuria  nia\'  accompany  any  of 
the  severe  an;vmias,  purpura,  scurv\',  or  syphilis.  Under  this 
heai-iiny;  ma>-  be  included  certain  cases  of  transient  albumin- 
uria occurring  during  pregnane}-. 

(f)  Ab)ionnai  Blood-iiigrcdioits,  such  as  alcohol,  bile- 
pigment,  sugar,  chronic  lead-  or  mercury-poisoning,  may 
induce  the  disease;  it  may  also  occur  after  the  administra- 
tion of  ether  or  chloroform.  Hyaline  casts  also  may  be 
present  in  bile-stained   urine. 

(f/)  Neurotic  causes,  probably  from  changes  in  the  blood- 
supply,  may  give  rise  to  the  condition,  as  after  epilepsy,  apo- 
plexy, tetanus,  or  injuries  to  the  head,  and  with  exophthal- 
mic goitre. 

{e)  Febrile  alhniniiiuria,  with  pyrexia  from  any  cause,  per- 
sisting during  the  period  of  fever.  Albumin  is  present  in 
small  quantities,  and  is  due  to  slight  changes  in  the  glom- 
eruli caused  by  the  febrile  process. 

(/)  Cyclic  or  periodic  albuminuria  is  a  form  occurring  in 
young  adults,  especially  in  boys,  in  which  albumin  appears 
at  certain  times  of  the  day.  It  seldom,  if  ever,  occurs  after 
rest  at  night,  but  usually  after  exertion  or  after  the  principal 
meal  of  the  day.  The  quantity  of  albumin  is  usually  small, 
although  it  may  be  considerable,  and  transient  glycosuria  or 
occasional  hyaline  casts  may  be  present. 

In  functional  albuminuria  there  is  neither  high  arterial 
tension  nor  hypertrophy  of  the  left  ventricle  of  the  heart, 
unless  from  some  intercurrent  affection,  and  neither  consti- 
tutional nor  uraemic  symptoms  are  present.  Cases  must 
always,  howex'er,  be  regarded  with  suspicion,  especially  if 
albumin  be  present  in  considerable  quantities  or  if  it  be  per- 
sistent. Albuminuria  in  persons  over  forty  years  of  age 
usually  indicates  changes  in  the  kidneys. 

3.  Albuminuria  with  Gross  Renal  Lesions. — [a)  Congestion 
of  the  kidney,  either  acute  or  chronic. 

(b)  Organic  disease,  acute  and  chronic  nephritis,  amyloid 
disease,  and  tumors. 

Tests. — The  urine   should   be    collected   for  twenty-four 


ANOA/ALIES   OF   I'l/J':    URINARY  SECRE'JVUjV.         563 

hours,  and  a  specimen  of  this  urine  should  be  taken  for 
examination.  If  the  urine  be  turbid,  it  should  be  filtered, 
unless  the  turbidity  be  due  to  urates,  in  which  case  a  little 
heat  will  clear  the  specimen. 

Heat-and-nitric-acid  Test. — The  urine  is  boiled  in  a  test- 
tube.  If  opacity  result,  it  is  due  either  to  albumin  or  to 
earthy  phosphates.  On  adding  a  few  drops  of  nitric  acid  the 
opacity  disappears  if  due  to  phosphates;  if  due  to  albumin, 
it  is  permanent.  This  is  the  best  routine  test  and  the  most 
satisfactory. 

Heller's  Test. — Upon  a  small  quantity  of  pure  colorless 
nitric  acid  in  a  test-tube  is  allowed  to  trickle  an  equal 
amount  of  clear  urine,  so  that  it  will  overlie  the  acid.  If 
albumin  be  present,  a  sharp  white  band  will  appear  at  the 
contact  of  the  two  liquids.  A  somewhat  similar  zone  may 
be  formed  by  the  action  of  nitric  acid  on  urates  if  in  excess, 
so  that  the  more  insoluble  acid  urates  are  precipitated.  This 
zone,  however,  is  not  sharply  defined,  diffuses  itself  into  the 
urine  above,  and  disappears  on  the  application  of  heat.  A 
haze  due  to  mucin  may  also  occur  above  the  albumin  zone, 
and  may  obscure  the  test. 

Picric-acid  Test. — A  saturated  solution  of  picric  acid  may 
be  used  as  in  Heller's  test.  Mucin,  peptone,  and  certain  alka- 
loids yield  an  opalescence  with  picric  acid,  but  this  opales- 
cence disappears  on  heating. 

Esbach's  test  is  valuable  in  the  quantitative  analysis  of 
albumin.  The  test-solution  is  made  by  dissolving  10  parts 
of  picric  acid  and  20  parts  of  citric  acid  in  900  parts  of 
boiling  distilled  water.  After  cooling,  a  sufficient  quantity 
of  distilled  water  is  added  to  make  a  total  of  1000  parts. 
The  graduated  tube  is  filled  with  urine  to  the  mark  U,  and 
then  with  the  reagent  to  the  mark  R.  The  liquids  are 
mixed  by  slowly  reversing  the  tube,  and  the  coagulu'm  of 
albumin  is  allowed  to  stand  for  twenty-four  hours.  The 
height  of  the  sediment  read  on  the  etched  scale  indicates 
the  weight  of  acid-albumin  in  grams  per  liter  of  urine. 

Other  tests  for  albumin  are  superfluous,  and  for  them  the 
reader  is  referred  to  books  on  urinary  analysis. 


564        .UJ.VC.il    of  the  rK.lCTICE    OF  MEDICINE. 
H/EMATURIA. 

Blood  in  the  urine  may  come  from  the  kidney,  the  pelvis 
of  the  kidney,  the  ureter,  the  bladder,  or  the  urethra. 

Rciial  JicuiorrJiagc  occurs  after  injuries  or  falls;  after 
acute  congestion  or  inflammation  ;  rarely  from  the  atrophic 
form  of  chronic  nephritis  ;  from  toxic  agents,  such  as  can- 
tharides,  carbolic  acid,  and  turpentine ;  from  embolism, 
thrombosis,  or  aneurysm  of  the  renal  vessels ;  from  tuber- 
cular inflammation ;  from  new  growths ;  from  calculous 
pyelitis ;  with  malignant  forms  of  acute  infectious  fevers,  as 
hemorrhagic  small-pox  or  "  black  measles  ;"  with  certain 
hemorrhagic  diseases,  as  scurvy,  purpura  htnemorrhagica,  or 
leukcXMiiia ;  as  evidence  of  vicarious  menstruation;  and  in 
some  )-oung  adults  as  a  simple  hemorrhage  without  known 
cause.  It  is  also  caused  in  the  tropics  by  the  parasites 
filaria  sanguinis  hominis  and  the  Bilharzia.  Malarial 
haematuria  is  endemic  in  certain  of  the  Southern  States. 

Hemorrhage  from  the  ureter  usually  implies  the  passage 
of  a  calculus. 

Hemorrhage  from  the  bladder  is  caused  by  injuries,  rough 
catheterization,  ulcers,  ruptured  veins,  new  growths,  and 
calculi. 

Hemorrhage  from  the  urethra  is  caused  by  traumatism, 
foreign  bodies,  calculi,  ulcers,  chancroids,  rough  catheteri- 
zation  or  injury,  and  gonorrhoea. 

Diagnosis. — Blood  in  the  urine  imparts  to  it  a  red  or 
brownish  color  and  gives  the  reaction  for  albumin.  Haema- 
turia is  to  be  distinguished  from  haemoglobinuria  by  the 
presence  of  red  blood-corpuscles.  Microscopical  examina- 
tion usually  renders  other  tests  superfluous. 

Hellers  test  for  blood-pigment  consists  in  boiling  the 
urine  with  a  solution  of  caustic  potash  until  flocculi  of 
phosphates  fall ;  these  flocculi  assume  a  red  color  from  the 
freed  haematin. 

The  guaiae7im  test  consists  of  the  addition  to  the  urine 
of  a  drop  or  two  of  tincture  of  guaiacum  and  two  minims  of 
ozonic  ether.  At  the  junction  of  the  two  fluids  a  blue  line 
forms,  which  becomes  diffused  through  the  ether.     Spectro- 


ANOAIAL/ES    OF   'J'HE    URINARY  SECRK'J'ION.         565 

scopic  examination  may  reveal  the  single  band  of  reduced 
haemoglobin  or   the  double  band  of  oxyhaemoglobin. 

Care  should  be  taken  to  exclude  the  admixture  of  men- 
strual blood  from  the  specimen  obtained  for  examination, 
and  bloody  urine  should  not  be  confounded  with  the  stain- 
ing by  rhubarb,  logwood,  and  a  few  other  dyes. 

Determination  of  the  Source  of  the  Hemorrhage. — In 
blood  from  the  kidney  the  blood  and  urine  are  intimately 
mixed,  and  there  may  be  blood-casts,  rendering  the  diag- 
nosis positive.  The  color  is  often  smoky.  Blood  from  the 
pelvis  and  the  ureter  is  frequently  passed  in  clots  which 
resemble  leeches  in  form  and  color. 

Blood  from  the  bladder  usually  is  passed  with  the  last  por- 
tion of  urine.  In  washing  out  the  bladder  the  water  comes 
away  blood-tinged,  whereas  if  the  source  of  hemorrhage 
were  from  the  kidney  the  water  would  come  away  clear. 

Hemorrhage  from  the  urethra  occurs  in  the  first  part  of 
micturition,  and  blood  frequently  escapes  in  the  intervals. 
Local  symptoms  aid  in  revealing  the  source  of  the  hemor- 
rhage. 

HEMOGLOBINURIA. 

Whenever,  from  any  cause,  the  red  blood-corpuscles  are 
dissolved  in  the  blood,  the  coloring  matter  thus  set  free  is 
excreted  as  methsemoglobin  in  the  urine,  imparting  to  it  a 
reddish-brown  color  which  may  in  extreme  cases  resemble 
that  of  porter.  The  urine  contains  granular  pigment  and  is 
albuminous,  but  usually  no  red  blood-corpuscles  are  pres- 
ent. If  present,  their  number  bears  no  proportion  to  the 
intensity  of  the  color  of  the  urine. 

Hsemoglobinuria  is  to  be  distinguished  from  haematuria 
by  the  absence  of  red  blood-corpuscles  ;  but  care  should  be 
taken  not  to  mistake  haemoglobinuria  for  bloody  urine  in 
which  the  corpuscles  have  been  dissolved  during  ammonia- 
cal  decomposition.  The  urine  reacts  to  Heller's  test  (see 
page  564)  and  gives  the  spectroscopic  absorption-bands  of 
metha;moglobin  or,  more  rarely,  of  oxyhaemoglobin. 

In  all  cases  of  haemoglobinuria  that  have  terminated 
fatally  a  secondary  nephritis  has  been  found. 

Two  clinical  groups  of  heemoglobinuria  are  described : 


566        M.lXr.tL    OF   THE   PKACT/CE    OF  MEDICIXE. 

1.  Toxic  HiC))ioglobiiiuria. — Dissolution  of  the  red  blood- 
corpuscles  can  occur  from  the  ingestion  of  certain  drugs, 
such  as  potassium  chlorate,  carbolic  acid,  pjTOgallic  acid, 
naphthol,  chloral,  arscniurettcd  h\-drogen,  and  muscarine. 
HaMiioglobinuria  occurs  after  transfusion  of  blood,  especially 
the  blood  of  animals  into  the  human  subject,  and  after  exten- 
sive superficial  burns  ;  it  is  said  also  to  occur  after  exposure 
to  cold.  It  may  occur  with  certain  infectious  diseases,  such 
as  t\'phoid  fever,  scarlet  fever,  malarial  fever,  j'ellow  fever, 
and  syphilis,  and  an  epidemic  form  of  hremoglobinuria  in 
the  new-born  has  been  described,  characterized  b}' jaundice, 
cyanosis,  and  nervous  symptoms. 

2.  Paroxysmal  Hccuioglohinuria. — This  form  is  character- 
ized by  the  passage  of  blood-pigment  in  the  urine  in 
attacks.  It  is  more  common  in  men  than  in  women,  and  it 
is  usually  seen  in  adults.  Attacks  may  be  induced  by 
exposure  to  cold  or  as  the  result  of  bodily  or  mental 
exhaustion.  Patients  suffering  from  Raynaud's  disease  are 
peculiarly  susceptible.  Severe  malarial  poisoning  may 
cause  either  hrematuria  or  hremoglobinuria,  the  changes  in 
the  urine  frequentl}'  showing  some  regular  periodicit}'. 
The  attacks  may  be  preceded  by  a  chill  and  a  rise  in  tem- 
perature, or  the  temperature  may  be  subnormal.  There 
may  be  yawning,  headache,  pain  in  the  bones,  vomiting, 
and  cramp-like  pains  over  the  hepatic  or  lumbar  region. 
The  hremoglobinuria  rarely  persists  for  more  than  one  day ; 
it  then  subsides,  and  is  followed  by  slight  jaundice  in  a 
considerable  number  of  cases.  Urticaria  after  the  paroxysm 
is  not  uncommon.  Ralfe  describes  cases  in  which  parox- 
ysms of  hat-moglobinuria  alternate  with  the  same  general 
symptoms,  but  with  the  passage  of  albumin  and  an  in- 
creased amount  of  urea. 

The  prognosis  of  the  toxic  form  of  hremoglobinuria 
depends  upon  the  severity  of  the  primary  disease ;  other- 
wise the  prognosis  is  good. 

Treatment  is  unsatisfactory.  Exposure  to  cold  should 
be  avoided  ;  quinine  should  be  given  in  malarial  cases,  and 
iodide  of  potassium  is  to  be  administered  should  a  syphilitic 
history    be    obtained.     During    the    parox}-sm   the    patient 


ANOMALIES   OF   Till':    URINARY   'SECR EI'ION.         567 

should    be    confined    to    bed,    kept   warm,   and    given    hot 
drinks. 


Pyuria  (Pus  in  the  Urine). 
Etiolog-y. —  I.  Pyelitis  and  Pyelonephritis. — The  pus  is 
uniformly  mingled  with  the  urine,  and  the  condition  of  the 
urine  is  unchanged  after  the  bladder  has  been  washed  out. 
In  calculous  and  tubercular  pyelitis  the  urine  is  usually  acid 
in  reaction,  but  in  pyelitis  complicating  cystitis  the  reaction 
is  usually  alkaline.  Large  abscesses  of  the  kidney  may 
suddenly  discharge  a  large  quantity  of  pus,  and  for  days  or 
weeks  afterward  the  urine  may  be  free. 

2.  Cystitis. — The  urine  is  alkaline,  often  ammoniacal. 
The  pus  is  passed  with  the  last  portions  of  the  urine,  and 
is  mixed  with  thick,  ropy  mucus.  The  urine  first  obtained 
after  the  bladder  has  been  washed  out  shows  decided  im- 
provement. 

3.  Urethritis. — The  pus  is  passed  with  the  first  portion 
of  the  urine,  and  may  escape  from  the  meatus  in  the  intervals 
of  micturition.  Local  symptoms  of  inflammation  are  usually 
evident. 

4.  LeiicorrJicea. — The  pus  is  small  in  quantity  and  is  ad- 
mixed with  vaginal  epithelium.  This  condition  may  be 
excluded  by  ordering  a  vaginal  douche  to  be  given  before 
micturition,  and  by  the  use  of  the  catheter. 

5.  Ruptnre  of  an  abscess  into  the  wnnary  passages  is 
characterized  by  a  sudden  irruption  of  pus. 


Peptonuria. 

Peptone  is  never  found  in  healthy  urine.  Traces  of  it 
are  found  in  some  acute  diseases,  in  suppurative  processes, 
and  with  disturbances  of  the  digestion  of  albuminous  sub- 
stances, but  the  peptonuria  possesses  no  diagnostic  value. 

Tests. — Peptone  is  not  precipitated  by  heat  or  by  nitric 
acid,  but  with  picric  acid  there  occurs  a  precipitate  which 
is  dissolved  by  heat.  A  supernatant  layer  of  urine  over 
Fehling's  solution  yields  a  rose-pink  halo. 


568        MANUAL    OF   THE   PRACTICE    OF  MFDICIXE. 

PllOSPHATURIA. 

Phosphates  occur  in  the  urine  as  alkaline  salts  of  sodium 
and  potassium  and  as  carlliy  salts  of  lime  and  magnesium. 
In  urine  undergoing  ammoniacal  fermentation  the  am- 
monio-magnesium  salt  or  the  triple  phosphates  may  appear. 

Phosphates  are  soluble  only  in  neutral  or  acid  urine,  and 
are  precipitated  whenever  the  urine  becomes  alkaline.  As 
they  are  less  soluble  in  hot  solutions,  the  phosphates  are 
often  precipitated  by  boiling,  even  in  urine  of  a  slightly  acid 
reaction,  and  may  be  mistaken  for  albumin  ;  but  the  speci- 
men rapidly  clears  up  upon  the  addition  of  acetic  acid.  If 
this  acid  be  added  to  the  specimen  before  boiling,  precipi- 
tation does  not  occur. 

Phosphates  may  appear  in  excess  (up  to  7  to  9  grams, 
whereas  from  2  to  3  grams  is  the  normal  quantity)  in  those 
suffering  from  debility,  dyspepsia,  or  wasting  disease.  There 
has  been  described  a  phosphatic  diabetes  characterized  by 
polyuria,  thirst,  loss  of  flesh,  and  an  absence  of  sugar  in  the 
urine.  In  some  cases  glycosuria  or  diabetes  has  followed 
this  condition. 

Lith/emia;   UriC/Emia. 

The  daily  amount  of  uric  acid  excreted  depends  largely 
upon  the  diet,  varying  from  10  to  30  grains,  the  relation  of 
uric  acid  to  urea  being  normally  as  i  :  33.  As  to  the  pro- 
duction and  antecedents  of  uric  acid  not  much  is  known 
accurately,  although  it  is  supposed  to  be  formed  in  the  liyer 
from  ammonia  and  lactic  acid.  It  is  also  unknown  whether 
it  represents  a  suboxidized  grade  of  urea  or  whether  it  has 
an  independent  origin.  Uric  acid,  being  practically  insolu- 
ble, is  eliminated  by  the  kidneys  chiefly  as  the  urates  of 
sodium  and  ammonium,  and  to  a  less  extent  as  the  urates 
of  potassium,  calcium,  and  lithium.  From  these  bases  uric 
acid  may  be  separated,  forming  the  "  red-pepper "  or 
"brick-dust"  deposits,  which  show  characteristic  appear- 
ances under  the  microscope.  As  conditions  which  cause 
the  precipitation  of  uric-acid  cr}'stals  from  the  urine 
Roberts  mentions — (i)  High  acidity;  (2)  poverty  in  min- 
eral salts ;  (3)  low  pigmentation  ;  and  (4)  high  percentage 


ANOMALIES    OF   THE    URINARY  SECREEION.         569 

of  uric  acid.  More  commonly  occurs  the  precipitation  of 
amorphous  urates,  chiefly  as  the  acid  sodium  urate,  in  the 
form  of  a  pinkish  deposit  occurring  as  the  urine  cools.  The 
urine  is  usually  concentrated,  of  high  specific  gravity,  and 
of  excessively  acid  reaction. 

The  power  which  the  blood  possesses  of  holding  uric 
acid  in  solution  depends  upon  its  degree  of  alkalinity. 
According  to  Haig,  the  excretion  or  the  retention  of  uric 
acid  can  be  regulated  by  increasing  or  diminishing  the  alka- 
linity of  the  blood.  His  theory  is  that  agents  increasing 
the  alkalinity,  finding  a  considerable  quantity  of  uric  acid 
in  the  liver,  the  spleen,  and  the  tissues,  render  its  solubility 
more  perfect,  so  that  it  is  taken  into  the  blood  and  excreted 
by  the  kidneys.  Pre-eminent  among  the  drugs  that  increase 
the  elimination  of  uric  acid  is  sodium  salicylate.  Among 
those  drugs -causing  retention,  the  most  important  are  acids. 
Haig  further  believes  that  drugs  affect  only  the  excretion 
of  uric  acid,  and  have  no  influence  whatever  upon  its 
formation. 

The  term  "  lithaemia  "  was  first  used  by  Murchison  to 
designate  symptoms  due  to  functional  disturbance  of  the 
liver  and  accompanied  by  an  increased  elimination  of  uric 
acid  or  urates ;  but  it  is  impossible,  in  the  present  state  of 
our  knowledge,  to  state  with  any  accuracy  the  pathology 
of  the  uric-acid  diathesis.  The  diathesis  bears  a  close 
relationship  to  gout,  so  that  it  has  been  termed  "  Amer- 
ican gout."  For  its  etiology  and  symptoinatology  see 
Irregular  Gout. 

OXALURIA. 

Oxalate  of  lime  is  held  in  solution  in  the  urine  by  the 
acid  sodium  phosphate.  The  crystals,  which  may  be  found 
deposited  in  small  quantities  under  certain  conditions,  are 
easily  recognized  under  the  microscope.  Oxaluria  occurs 
after  eating  certain  fruits  and  vegetables,  as  tomatoes, 
rhubarb,  apples,  pears,  and  cauliflower.  It  occurs  also  in 
gouty,  hypochondriacal,  and  neurasthenic  patients,  as  the 
result  of  imperfect  oxidation-processes.  Oxaluria  is  also 
said  to  result  from  acid  fermentation  of  the  urine  within  the 
urinary  passages. 


570     M.i.vr.iL  OF  THE  pmact/ce  of  medicine. 

Chvi.ukia. 
Rare  cases  of  chyluria  result  from  some  connection 
between  the  lymphatic  vessels  and  the  urinary  passages,  but 
the  exact  pathology  is  unknown.  In  the  tropics  chyluria 
is  not  infrequently  associated  with  the  presence  of  the  filaria 
sanguinis  hominis.  The  urine  is  milky  in  appearance  and 
contains  emulsified  fat  and  serum-albumin.  There  may 
occur  a  spontaneous  clot  resembling  blanc-mangc,  or  the 
fat-globules  may  rise  to  the  surface  like  cream.  The 
microscope  shows  fine  fat-globules  which  dissolve  in  ether. 

IXDICANURIA. 

Indigo  appears  in  the  urine,  not  in  the  free  state,  but  in 
combination  as  indoxyl-sulphate  of  potassium,  which  is  a 
compound  originally  derived  from  indol.  Indol  itself  is 
formed  in  the  small  intestine  by  the  action  of  bacteria  upon 
albumin.  When  concentrated  acids  are  added  to  the  urine 
containing  the  indoxyl-sulphate,  indigo  is  liberated. 

Indicanuria  is  frequent  in  all  wasting  and  cachectic 
diseases  associated  with  the  excessive  destruction  of  albu- 
minoids. It  may  occur  with  tumors  of  the  intestines  and 
the  pancreas,  in  intestinal  obstruction,  and  in  prolonged 
constipation.     It  is  increased  by  a  milk  diet. 

Glycosuria. 
It  is  a  generally  accepted  belief  that  sugar  does  not  occur 
in  normal  urine.     The  occurrence  of  glycosuria  with  patho- 
logical conditions  will  be  considered  elsewhere,  under  the 
same  heading. 

LiPURIA. 

Fat  may  appear  in  the  urine  after  an  excessive  quantity 
of  fat  has  been  taken  with  the  food,  with  prolonged  sup- 
puration, with  pancreatic  tumors  and  degeneration,  after 
phosphorus-poisoning,  and  in  diabetic  urine.  The  occur- 
rence of  chyluria  has  already  been  described.  Lipuria  may 
also  occur  with  ad\'anced  Bright's  disease  and  with  pyo- 
nephrosis. 


CHRONIC  CONGESTION  OF   THE   KIDNEYS.  57 1 

ACETONURIA. 

Acetone,  according  to  Von  Jaksch,  may  occur  with  fevers, 
diabetes,  cancer,  inanition,  in  certain  mental  conditions,  and 
as  a  form  of  auto-intoxication. 

For  the  clinical  and  microscopical  detection  of  the  above- 
mentioned  ingredients  of  the  urine  the  reader  is  referred  to 
books  on  urinary  analysis. 

ACUTE    CONGESTION    OF    THE    KIDNEYS. 

Etiology. — Acute  congestion  of  the  kidneys  may  follow 
the  taking  of  certain  poisons  (as  cantharides),  the  removal  of 
one  kidney,  or  the  sudden  blocking  of  one  ureter  by  a  cal- 
culus, by  over-exertion,  or  by  surgical  operations,  especially 
on  the  bladder  and  the  urethra. 

Pathology. — The  lesion  consists  in  the  temporary  con- 
gestion of  the  blood-vessels  of  the  kidney,  allowing  of  the 
exudation  of  serum  and  the  escape  of  red  blood-cells. 

Symptoms. — The  urine,  which  is  diminished  in  quantity 
or  suppressed,  according  to  the  degree  of  congestion,  may 
contain  blood,  albumin,  and  casts.  Its  specific  gravity  is 
not  changed.  The  urinary  symptoms  may  last  for  a  few 
days  with  considerable  prostration,  and  may  then  disappear; 
or  the  symptoms  may  continue,  and  the  patient  becomes 
more  feeble  and  prostrated,  passes  into  a  typhoid  state  with 
delirium,  and  dies.  These  bad  cases  are  those  following  the 
removal  of  one  kidney,  impaction  of  a  calculus,  or  surgical 
operations  on  the  bladder  and  the  urethra. 

The  prognosis  in  mild  cases  is  good.  Repeated  attacks 
induced  by  over-exertion  or  by  irritant  drugs  may  event- 
ually lead  to  nephritis. 

Treatment. — The  patient  is  to  be  kept  warm  in  bed,  on  a 
liquid  diet,  and  the  bowels  are  to  be  moved  freely.  Sweat- 
ing should  be  induced  by  pilocarpine  or  by  the  hot  pack  or 
the  hot-air  bath. 

CHRONIC    CONGESTION    OP    THE    KIDNEYS. 
Etiology   and    Synonym. — Chronic    congestion    of  the 
kidneys  is  induced  by  any  cause  preventing  the  free  escape 


57-        M.l.XL.lI.    OF   77/E   rh'.lC77CK    OF  MFDICIXE. 

of  blood  from  the  renal  \-eins,  such  as  the  pressure  of  ab- 
dominal growths  or  that  occurrinijj  in  tlic  course  of  chronic 
conj^estion  of  the  viscera  due  to  heart  disease  or  to  cmpln-- 
sema.     Syncviyiii :  Cyanotic  induration. 

Pathology. — The  kidneys  are  normal  or  increased  in  size 
and  are  heavy  and  hard.  The  capsule  is  not  adherent ;  the 
surface  is  smooth.  The  organ  is  congested,  red,  and  livid, 
or  the  pyramids  are  red  while  the  cortex  is  pink  or  white. 
A  considerable  number  of  the  glomeruli  are  large,  their  capil- 
laries are  dilated,  and  the  cells  covering  the  capillaries  are 
swollen.  Aside  from  a  slight  increase  in  the  subcapsular 
connective  tissue,  the  stroma  is  unchanged.  Such  kidneys 
are  apt  to  develop  chronic  diffuse  nephritis.  In  heart  dis- 
ease with  visceral  congestions  chronic  diffuse  nephritis 
occurs  in  60  per  cent.,  chronic  congestion  in  40  per  cent. 
Symptoms. — The  urine  is  diminished  in  quantity  but  is 
of  good  quality,  the  amount  of  urea  to  the  ounce  being 
rather  increased  than  diminished.  The  specific  gravity  is 
normal  or  high.  Albumin  and  casts  may  be  present  in 
small  quantities,  but  are  often  absent.  A  continual  precipi- 
tation of  urates  should  excite  suspicion  of  chronic  conges- 
tion, and  the  heart  and  lungs  should  be  carefully  examined. 
The  general  symptoms  are  slight  or  unnoticed.  Urremic 
symptoms  do  not  occur. 

Treatment  should  be  directed  toward  the  disease  causing 
the  congestion. 

ACUTE    DEGENERATION    OP  THE    KIDNEYS. 

Etiolog-y  and  Synonyms. — Acute  degeneration  of  the 
kidneys  is  always  secondary  to  the  introduction  of  poisons 
into  the  body.  It  complicates  poisoning  by  arsenic,  mer- 
cury, and  phosphorus,  or  by  the  organic  poisons  which 
result  from  severe  infectious  diseases  or  from  injuries. 
Acute  degeneration  is  usually  found  in  the  kidneys  of 
those  who  have  died  from  infectious  diseases.  Synonjnns  : 
Acute  Bright's  disease;  Parenchymatous  nephritis;  Paren- 
chymatous degeneration. 

Pathology. — The  kidneys  are  more  or  less  enlarged ; 
the  capsules  are  not  adherent ;  the  surfaces  are  smooth  ;  the 


CHRONIC  DEGENERATION  OE    THE    KIDNEYS.      573 

cortex  is  usually  thickened,  and  it  may  be  either  pale  or 
congested.  There  are  changes  in  the  renal  cells,  especially 
marked  in  those  of  the  convoluted  tubes.  These  changes 
consist  in  (i)  swelling,  (2)  granular  infiltration  with  albumi- 
noid matter  and  fat,  (3)  death  of  the  cells,  with  desquama- 
tion, (4)  a  formation  of  hyaline  masses  in  the  cells,  and  (5) 
a  o-rowth  of  new  cells  to  replace  the  dead  epithelium.  In 
severe  cases  there  is  added  congestion  of  the  blood-vessels, 
with  exudation  of  serum.  There  are  no  changes  in  the 
stroma. 

Symptoms. — The  urine  is  diminished  according  to  the 
severity  of  the  disease.  It  may  even  be  suppressed.  Its 
specific  gravity  is  unchanged.  Albumin  and  casts  are  usually 
present,  from  the  congestion  and  exudation,  and  blood-cells 
appear  in  severe  cases.  The  general  symptoms  are  usually 
obscured  by  those  of  the  primary  disease.  In  mild  cases 
accompanying  infectious  diseases  there  are  no  symptoms, 
excepting  the  presence  of  albumin  and  casts  in  small  amounts 
in  the  urine.  In  severe  cases  accompanying  yellow  fever 
and  acute  yellow  atrophy  of  the  liver,  and  following  the 
ingestion  of  an  inorganic  poison,  the  urinary  changes  are 
marked  :  the  patient  becomes  feeble,  passes  into  the  typhoid 
condition,  and  dies,  apparently  from  the  kidney-lesion. 
Dropsy  is  not  noticeable  in  these  cases. 

The  prognosis  is  good  except  in  the  severe  cases.  Albu- 
min and  casts  may,  however,  persist  for  some  time  after  the 
subsidence  of  the  primary  disease. 

Treatment. — There  is  no  treatment  to  prevent  the  degen- 
erative changes.  When  exudation  occurs  the  treatment  of 
acute  exudative  nephritis  is  indicated. 

CHRONIC    DEGENERATION    OF    THE    KIDNEYS. 

Etiology  and  Synonyms. — The  process  is  secondary  to 
any  of  the  mechanical  causes  of  chronic  congestion,  to 
vicious  modes  of  life,  and  to  chronic  alcoholism.  Synonyms : 
Chronic  Bright's  disease ;  Chronic  parenchymatous  nephri- 
tis ;  Fatty  kidney. 

Pathology. — The  kidneys  are  usually  increased  in  size, 
although  exceptionally  they  may  be  normal  or  even  small. 


574        -V.l.vr.lL    0J-'  THE   PRACTICE    OE  MEDICIA'E. 

The  surface  is  smooth  ;  the  pyramids  are  red ;  the  cortex  is 
white,  yellow,  or  pink.  There  are  swelling,  granular  degen- 
eration, and  fatt>'  infiltration  of  the  epithelium  of  the  cortex. 
There  are  no  changes  in  the  stroma.  The  glomeruli  are 
normal  unless  the  degeneration  be  due  to  venous  congestion. 

Symptoms. — The  quantit)'  of  urine  varies  in  different 
patients  and  at  different  times  ;  it  may  be  increased,  normal, 
scanty,  or  the  urine  may  be  suppressed.  The  specific  grav- 
ity of  the  urine  and  the  proportion  of  urea  excreted  are 
unchanged.  Albumin  and  casts  in  moderate  amounts  are 
usuall}^  present.  The  patient  becomes  anaemic  and  loses 
flesh  and  strength.  In  bad  cases  he  may  pass  into  the 
t)-phoid  state,  with  delirium  and  stupor.  Dropsy  does  not 
develop.    The  disease  may  be  followed  b\'  chronic  nephritis. 

The  prognosis  is  not  good,  as  the  natural  tendency  of 
the  disease  is  to  progress. 

Treatment  is  not  satisfactory.  Vicious  and  alcoholic 
habits  are  to  be  checked.  The  diet  and  the  mode  of  life 
are  to  be  regulated.  The  circulatory  changes  inducing 
venous  congestion  are  to  receive  appropriate  treatment. 

ACUTE   EXUDATIVE   NEPHRITIS. 

Etiology  and  Synonyms. — Primary  cases  may  occur 
after  exposure  to  wet  and  cold,  or  without  assignable  cause. 
Secondary  cases  accompany  an}-  of  the  severe  infectious  dis- 
eases or  the  puerperal  state.  SyiionyiNs:  Parench}'matous 
nephritis;  Tubal  nephritis;  Desquamative  nephritis;  Ca- 
tarrhal nephritis  ;   Croupous  nephritis  ;  Glomerulo-nephritis. 

Pathology. — The  chief  lesion  is'  in  the  blood-vessels. 
From  the  tuft  there  is  an  exudation  of  plasma  and  of 
red  and  white  blood-cells  wliich  infiltrate  the  stroma  of  the 
kidney  and  collect  as  casts  and  cellular  masses  in  the  tubes, 
from  which  they  may  be  voided  in  the  urine.  The  amount 
of  exudation  varies  with  the  severity  of  the  case.  In  severe 
cases  there  may  be  an  over-production  of  pus-cells. 

In  mild  cases  the  kidney  shows  no  changes,  the  conges- 
tion having  disappeared  and  the  exuded  material  having 
been  passed  in  the  urine. 

In  severe  cases  the  kidney  is  large,  the  surface  is  smooth, 


ACUTE   EXUDATIVE   NEI'IIh' /I'fS.  575 

the  cortex  is  thick  and  white  or  red  and  white,  or  the  whole 
kidney  is  congested  and  succulent.  Within  the  tubes,  espe- 
cially those  of  the  cortex,  are  irregular  masses  of  coagulated 
material,  forming  casts,  and  frequently  white  and  red  blood- 
cells.  There  may  be  dilatation  of  the  cortical  tubes,  and  their 
epithelium  may  be  swollen,  degenerated,  or  detached.  The 
cells  covering  the  tuft  are  usually  swollen  and  increased  in 
number.  In  other  cases  there  is  an  excessive  emigration 
of  white  blood-cells,  which  infiltrate  the  stroma  and  appear 
as  small  whitish  foci  in  the  cortex.  The  amount  of  serum 
exuded  from  the  tuft  is  not  proportionately  increased,  so 
that  it  is  possible  in  this  form  to  have  little  or  no  albumin 
and  casts  in  the  urine. 

Symptoms. — In  mild  cases  the  patient  complains  of  gen- 
eral malaise,  with  slight  headache,  loss  of  appetite,  and  per- 
haps some  aching  in  the  back.  The  urine  is  slightly  dimin- 
ished in  quantity,  the  specific  gravity  is  about  normal,  and 
albumin  is  present  in  considerable  quantity,  with  hyaline, 
granular,  and  epithelial  casts,  sometimes  with  red  and  white 
blood-cells.  The  constitutional  symptoms  last  for  from 
one  to  two  weeks  ;  albumin  and  casts  persist  for  four  or  six 
weeks  and  then  disappear. 

In  severe  cases  there  is  fever,  with  prostration,  loss  of 
appetite,  nausea,  a  pulse  of  high  tension,  and  exaggerated 
heart-action.  Anaemia  is  rapidly  developed.  There  may 
appear  the  symptoms  of  acute  uraemia  due  to  contracted 
arteries — stupor,  headache,  dyspnoea,  restlessness,  muscular 
twitchings,  or  general  convulsions.  Dropsy  may  be  de- 
veloped, usually  appearing  first  in  the  face.  The  urine  is 
diminished  in  quantity,  and  contains  albumin,  casts,  and 
cells  in  proportion  to  the  severity  of  the  inflammation. 
Constitutional  symptoms  last  about  four  weeks.  Albumin 
and  casts  continue  in  the  urine  for  weeks  afterward. 

The  cases  zvitli  abundant  production  of  pus-cells  occur  in 
children  and  in  adults  as  a  primary  disease  or  secondary 
to  measles,  scarlet  fever,  and  diphtheria.  The  invasion  is 
sudden,  with  fever  and  prostration.  Restlessness,  delirium, 
headache,  and  stupor  appear  early  in  the  disease  and  con- 
tinue throughout  its  course.     Dropsy  is  slight   or  absent. 


5/6        MAXCAL    OJ-'   THE   PRACTICE    OE  MEDICIXE. 

The  patient  loses  flesh  and  strength,  passes  into  the  typhoid 
condition,  and  is  apt  to  die. 

The  urine  is  not  much  diminished  in  quantity;  its  specific 
gravity  is  normal.  Albumin,  casts,  and  red  and  white 
blood-cells  are  usually  present  in  considerable  quantity,  but 
they  may  not  appear  until  late  in  the  disease.  In  other 
cases  albumin  and  casts  are  scanty  or  are  absent  altogether. 

The  prognosis  of  mild  cases  is  good.  The  development 
of  uraemic  symptoms  in  the  severe  cases  causes  anxiety,  but 
a  decided  majority  of  the  cases  recover  completely.  The 
cases  with  abundant  production  of  pus-cells  are  apt  to 
terminate  fatally.  It  is  possible  for  the  disease  to  be  fol- 
lowed by  chronic  nephritis. 

Treatment. — The  patient  should  be  put  to  bed  on  a  milk 
diet.  In  mild  cases  the  liberty  of  the  house  may  be  allowed. 
The  bowels  should  be  kept  open  by  calomel  or  by  sulphate 
of  magnesium  in  small  repeated  doses,  and  the  skin  should 
be  rendered  active  by  hot  baths,  daily  cleansing,  and  skin- 
friction.  Applications  of  wet  or  dry  cups  or  hot  poultices 
to  the  lumbar  region  may  be  of  service.  The  cerebral 
symptoms  during  the  early  part  of  the  disease,  being  due  to 
contraction  of  the  arteries  with  labored  heart-action,  should 
be  controlled  by  arterial  dilators.  Of  these,  the  best  are 
aconite,  chloral  hydrate,  nitroglycerin,  and  opium,  in  small 
repeated  doses  before  the  cerebral  symptoms  are  marked,  and 
in  larger  doses,  hypodermically  and  by  the  rectum,  during  an 
attack.  As  the  nephritis  subsides  the  milk  diet  is  replaced 
by  solid  food,  iron  and  oxygen  are  given  for  the  anaemia,  and, 
if  possible,  the  patient  is  sent  to  a  warm,  dry  inland  place 
until  convalescence  is  complete. 

ACUTE    DIFFUSE    NEPHRITIS. 

Etiology  and  Synonyms. — Primary  cases  of  acute  diffuse 
nephritis  follow  exposure  to  wet  and  cold.  Secondary  cases 
complicate  scarlet  fever,  diphtheria,  and  pregnancy.  The 
disease  is  more  common  in  children  and  young  adults. 
Synonyms:  Acute  productive  nephritis;  Acute  Bright's 
disease;  Croupous  nephritis. 

Pathology. — The  kidneys  are  large ;  the  capsule  is  not 


ACU'/7':   J) //■•/-'USE   NIC /'//A' /'/vs.  577 

adherent  unless  in  cases  of  old  standing,  in  which  event  the 
surface  may  also  be  roughened  ;  the  cortex  is  thick,  white, 
mottled  yellow  and  red,  or  congested ;  the  pyramids  are 
red.  The  microscope  shows  the  same  lesions  as  in  acute 
exudative  nephritis,  with  two  additional  features  :  First,  a 
growth  of  connective  tissue  in  the  cortex ;  second,  a  growth 
of  the  capsule-cells  of  the  Malpighian  tufts.  These  changes 
do  not  occur  throughout  the  entire  kidney,  but  in  symmet- 
rical wedges  in  the  cortex,  following  the  line  of  the  arteries. 
These  wedges  may  be  small  or  large,  few  or  numerous,  reg- 
ular or  irregular.  Each  wedge  has  the  same  general 
characters  : 

First,  one  or  more  arteries  which  run  toward  the  cortex, 
the  walls  of  which  are  thickened. 

Second,  the  Malpighian  bodies  connected  with  the  affected 
artery  show  an  increased  growth  of  capsule-cells,  causing 
compression  of  the  tufts.  There  is  also  a  growth  of  the  cells 
covering  the  vessels  and  within  them,  as  in  exudative  nephri- 
tis. The  tuft  never  returns  to  a  normal  condition,  but  in 
time  the  vessels  are  obliterated  and  the  glomeruli  are 
transformed  into  little  balls  of  fibrous  tissue. 

Third,  a  growth  of  connective  tissue  in  the  stroma  paral- 
lel with  the  affected  arteries.  This  connective  tissue  is  at 
first  composed  largely  of  cells ;  later  the  tissue  becomes 
denser.  If  the  growth  of  connective  tissue  be  abundant, 
the  tubes  within  the  wedge  become  atrophied. 

Between  the  wedges  are  seen  the  lesions  of  exudative 
nephritis ;  later  there  is  developed  a  diffused  growth  of 
connective  tissue. 

The  disease  is  serious  not  only  from  the  disturbed  func- 
tions of  the  kidney  induced,  but  also  because  of  the  perma- 
nent character  of  the  lesion. 

Symptoms. — The  invasion  may  be  sudden  or  gradual. 

The  acute  cases  begin  with  fever  and  prostration,  pain  in 
the  back,  and  frequent,  scanty  micturition.  There  are 
symptoms  of  acute  uraemia,  a  pulse  of  high  tension  with 
exaggerated  heart-action,  or  hypertrophy  of  the  left  ven- 
tricle, loss  of  appetite,  nausea  or  vomiting,  stupor,  headache, 
muscular  twitchings,  or  even  convulsions.  The  patient  be- 
37 


5/8        M.lXC.tL    OF   THE   PKACriCE    OE  MEDICIWE. 

comes  rapidly  an;uinic.  and  dropsy  appears,  usuall\'  first  in 
the  face ;  tlie  dropsy  may  become  general.  The  urine  is 
smoky  or  bloody  in  color,  scanty  or  even  suppressed,  of  a 
low  specific  gravity,  and  contains  albumin  and  casts  in  con- 
siderable quantities,  with  renal  epithelium,  and  sometimes 
with  pus-cells.  These  acute  cases  resemble  cases  of  acute 
exudative  nephritis,  but  the  specific  gravity  of  the  urine  is 
lower  and  the  patient  is  more  apt  to  die.  At  the  end  of 
about  four  weeks,  however,  the  patient  may  apparently  re- 
cover, although  albumin  and  casts  still  persist  in  the  urine. 
In  course  of  time  s\-mptoms  of  chronic  nephritis  appear. 

The  subacute  cases  are  more  frequent.  The  first  symp- 
toms are  often  referred  to  the  stomach — loss  of  appetite, 
nausea,  and  vomiting.  In  other  patients  dropsy  is  the  first 
.symptom  complained  of  Anaemia,  headache,  sleepless- 
ness, and  dyspnoea  usually  appear  early  in  the  -disease.  The 
urine  is  diminished  in  quantity,  is  of  a  low  specific  gravity, 
and  may  or  may  not  contain  blood.  Albumin  and  casts 
are  present,  the  former  usually  in  considerable  quantity. 
The  patient  becomes  gradually  worse.  Acute  uraemia 
from  contracted  arteries  is  shown  by  high-tension  pulse, 
exaggerated  heart-action  or  hypertrophy,  with  or  without 
some  dilatation  of  the  left  ventricle,  headache,  restlessness, 
and  muscular  twitchings  or  convulsions.  Chronic  uremia 
is  shown  by  alternating  delirium  and  stupor,  with  a  feebly 
acting  heart  and  low  arterial  tension.  The  attack  may  last 
for  weeks  or  months,  and  from  it  the  patient  ma)^  die. 
Other  patients  apparently  recover,  but  the  urine  still  con- 
tains albumin  and  casts  and  is  of  low  specific  gravity. 
There  are  usually  subsequent  attacks,  which  must  be  re- 
garded as  acute  exacerbations  of  an  established  chronic 
nephritis. 

The  prognosis  is  bad,  the  patient  dying  either  in  the 
acute  attack  or  from  the  chronic  nephritis  that  follows.  In 
many  cases  life  may  be  prolonged  for  a  number  of  years. 

Treatment. — In  the  acute  cases  the  treatment  is  the 
same  as  that  for  exudative  nephritis,  except  that  more 
care  should  be  employed  during  convalescence,  and  pro- 


CHRONIC  JSKIGUT'S  DISEASE.  579 

longed    residence    in    a    warm     inland    climate    should    be 
recommended. 

In  the  subacute  cases  the  nephritis  is  best  treated  by  rest 
in  bed  on  a  milk  diet.  The  milk  diet  should  be  continued 
for  a  few  weeks,  and  should  then  gradually  be  replaced  by 
solid  food.  Later,  residence  in  a  warm,  dry  climate  for 
some  months  at  least  should  be  insisted  upon.  Anaemia  is 
to  be  treated  by  iron,  oxygen,  and  fresh  air.  The  dropsy 
is  best  treated  by  rest  in  bed  on  a  milk  diet.  If  the  dropsy 
be  persistent,  diuretics,  cathartics,  and  the  hot  pack  or  the 
hot-air  bath  may  be  employed.  The  condition  of  the  heart 
and  the  arteries  should  be  watched  continually.  If  the 
arteries  be  contracted,  with  a  pulse  of  high  tension  and  an 
exaggerated  heart-action,  arterial  dilators  should  be  used. 
Among  the  best  of  these  are  nitroglycerin,  chloral  hydrate, 
opium,  and  potassium  iodide.  If  the  heart  be  feeble,  with 
low-tension  pulse,  and  if  symptoms  of  chronic  uraemia  appear, 
digitalis,  strophanthus,  caffeine,  or  strychnine  is  indicated. 
In  all  cases  the  patient  should  be  watched  during  convales- 
cence, and  the  general  health  should  be  improved  in  every 
possible  way.  The  selection  of  a  suitable  warm  climate  is 
of  the  very  first  importance  in  these  cases. 

CHRONIC    BRIGHT' S    DISEASE. 

Although  two  forms  of  chronic  nephritis  are  described, 
one  with  and  one  without  exudation  from  the  blood-vessels, 
practically  the  same  lesions  are  found  in  both.  The  only 
real  difference  is  that  in  one  form  exudation  from  the  vessels 
is  added.  In  chronic  nephritis  with  exudation  albumin  is 
nearly  constantly  present  in  the  urine,  although  it  may  be 
absent  for  short  periods.  In  chronic  nephritis  without 
exudation  albumin  is  generally  absent,  although  it  may  be 
present  at  times  in  considerable  quantity.  The  presence  or 
absence  of  albumin  seems  to  vary  the  clinical  symptoms  of 
the  disease  to  some  extent. 

Chronic  Diffuse  Nephritis  with  Exudation. 
Etiology  and  Synonyms. — Primary  cases  occur  in  young 
and  middle-aged  adults,  being  somewhat  more  common  in 


580        .V.I.VrJL    OF   THE   PKACriCE    OF  MEDICIXE. 

males.  The  disease  may  follow  acute  diffuse  nephritis, 
whether  from  cold,  scarlet  fever,  or  pregnancy,  and  it  occurs 
after  chronic  congestion  and  chronic  degeneration  of  the 
kidney.  It  may  complicate  syphilis,  endocarditis,  chronic 
phthisis,  and  prolonged  suppuration,  especially  of  bones 
and  joints,  and  it  is  usually  associated  witii  am)'loid  degen- 
eration of  the  kidney.  Synoityins :  Chronic  parenchyma- 
tous nephritis;  Large  white  kidney;  Small  white  kidney; 
Chronic  desquamative  nephritis ;    Chronic  tubal    nephritis. 

Pathology. — The  kidneys  are  usually  large,  with  smooth 
or  roughened  surfaces  ;  the  cortex  is  pale.  This  condition 
is  spoken  of  as  the  "  large  white  kidney."  In  other  cases 
the  kidney  is  small,  with  a  pale  cortex,  forming  the  "  small 
white  kidney."  In  rare  cases  the  kidney  may  appear  to  the 
eye  to  be  normal.  Microscopically  the  following  changes 
are  described  by  Delafield  :  "  There  is  a  very  extensive 
growth  of  connective  tissue  in  the  cortex ;  the  renal  epithe- 
lium is  swollen,  granular,  degenerated,  fatty,  broken,  or  flat- 
tened ;  the  tubes  contain  coagulated  matter,  cast  matter,  or 
blood  ;  the  cortex-tubes  are  atrophied  in  some  places,  dilated 
in  others. 

"The  glomeruli  are  changed  in  several  different  ways: 

"  I.  There  is  a  growth  of  the  capsule-cells  in  such  num- 
bers that  they  compress  the  tufts.  The  cells  covering  the 
capillaries  are  also  increased  in  size  and  number.  The 
capsule-cells  may  finally  be  changed  into  connective  tissue, 
and  the  tufts  become  atrophied. 

"2.  The  glomeruli  are  of  large  size;  the  cells  covering 
the  capillaries  are  increased  in  number,  so  that  the  outlines 
of  the  capillaries  are  lost,  but  yet  the  capillaries  are  not 
compressed  nor  are  the  glomeruli  atrophied. 

"  3.  There  is  a  growth  of  the  cells  which  cover  the  capil- 
laries and  of  the  cells  within  them.  Of  the  cells  which  cover 
the  capillaries,  the  cell-bodies  become  very  large,  the  capil- 
laries are  compressed,  and  the  glomeruli  eventually  become 
atrophied. 

"4.  The  walls  of  the  capillary  vessels  become  the  seat 
of  waxy  degeneration,  while  the  cells  which  cover  them  arc 
increased  in  size  and  number. 


CIIKOA'JC   JSR/CJIT'S  DIS/'IASK.  581 

"5.  If  the  nepliritis  follows  chronic  congestion,  the  capil- 
laries are  dilated,  and  there  is  an  increase  in  the  size  and 
number  of  the  cells  which   cover  the  capillaries. 

"  The  arteries  remain  unchanged,  or  they  are  the  seat  of 
obliterating  endarteritis,  or  there  is  a  symmetrical  thicken- 
ing of  all  the  coats  of  the  artery,  or  all  the  coats  of  the  artery 
are  thickened  and  converted  into  a  uniform  mass  of  connec- 
tive tissue,  or  there  is  waxy  degeneration  of  the  walls  of  the 
artery." 

Symptoms. — i.  Changes  in  the  Urine. — The  quantity 
varies  at  different  times.  When  the  inflammation  is  quies- 
cent the  quantity  may  be  normal ;  during  an  acute  exacer- 
bation the  urine  is  diminished  or  suppressed.  In  some 
cases,  when  the  patient  is  doing  badly,  even  if  there  be 
dropsy,  the  urine  is  increased.  The  specific  gravity  and 
the  amount  of  urea  to  the  ounce  slowly  diminish.  The 
gravity  varies  usually  between  looi  and  1012.  Low  specific 
gravity  indicates  extensive  connective-tissue  growth  in  the 
cortex  or  waxy  degeneration  of  the  capillaries  of  the  glo- 
meruli. Albumin  and  casts  are  almost  constant  in  con- 
siderable quantities ;  they  are  increased  during  acute  ex- 
acerbations, and  at  other  times,  when  the  lesion  is  quiescent, 
they  may  diminish,  and  may  even  disappear  for  short 
periods. 

2.  Dropsy  is  a  prominent  symptom,  and  is  rarely  absent. 
It  may  occur  early  or  late,  or  only  in  periods. 

3.  Ancemia  is  most  marked,  and  may  even  resemble  per- 
nicious anaemia.  There  is  a  peculiar  pallor  of  the  skin 
which  is  quite  characteristic. 

4;  Acute  nresmic  symptoms,  with  contracted  arteries,  caus- 
ing convulsions,  etc.,  are  not  as  common  as  in  the  cases 
without  exudation. 

5.  Chrojiic  tirczmia,  with  soft,  feeble  pulse,  delirium,  and 
stupor,  is  common,  especially  toward  the  close  of  the 
disease. 

6.  HeadacJie,  restlessness  and  sleeplessness,  loss  of  appe- 
tite, nausea,  and  vomiting  frequently  occur. 

7.  Neuro-retinitis  and  nepJiritic  retinitis  are  not  as  common 
as  in  the  cases  without  exudation. 


5^2        J/.I.VC.IL    OF   TJIE   PRACTICE    OF  MEDICIXF. 

8.  Dyspihva  is  ne;irl>-  constant.  It  nia\'  be  due  to  liydro- 
thorax,  to  cedema  of  the  luntj^s,  to  failuie  of  the  lieart.  or  to 
contraetion  of  the  arteries.  In  many  cases  spasmodic 
d\'.spnoea  occurrinij  at  nii;ht  or  in  the  early  mornintj,  and 
aggravated  by  l>'ing  down,  ma\-  be  the  first  symptom 
noticed. 

9.  The  tciisioi  of  Ihc  pulse  is  usuall\-,  but  not  always,  in- 
creased. There  ma\-  be  hypertrophy  or  dilatation  of  the 
left  \'entricle,  myocarditis,  or  feeble  heart. 

Course  of  the  Disease. — The  constant  symptoms  are 
(i)  albumin  in  the  urine,  (2)  dropsy,  and  (3)  anaemia. 

1 .  In  some  cases  the  symptoms  are  continuous,  the  patient 
dying  from  chronic  urcxmia  or  dropsy  in  from  one  to  two 
years. 

2.  The  symptoms  come  in  attacks.  Between  the  attacks 
the  patient  feels  well,  although  the  urine  contains  albumin 
and  is  usually  of  low  specific  gravity.  The  interval  between 
the  attacks  may  be  weeks,  months,  or  even  years. 

3.  Some  patients  live  for  years  with  only  pallor  of  the 
skin  and  albumin  in  the  urine,  feeling  well  otherwise. 

4.  There  may  be  an  attack  of  spasmodic  dyspnoea  in  a 
time  of  supposed  good  health.  Years  may  intervene  before 
symptoms  are  developed. 

5.  There  may  be  a  history  of  chronic  endocarditis,  con- 
gestion of  the  kidney,  or  acute  diffuse  nephritis  before  the 
regular  symptoms  of  the  disease  appear. 

6.  A  few  cases  apparently  recover,  especialh'  in  children. 
The   prognosis   is  bad,  although   life   may  be  prolonged 

for  years. 

Treatment. — The  amount  of  urine  should  be  increased 
by  drugs  or  by  so  regulating  the  diet  of  food  and  liquids 
that  the  patient  passes  sixty  ounces  of  urine  a  day. 

The  dropsy  is  to  be  treated  by  rest  in  bed,  diuretics,  and 
cathartics.  Arterial  dilators  or  heart-stimulants  are  indicated 
to  meet  the  respective  errors  in  the  circulatory  system. 

Anaemia  requires  iron,  arsenic,  and  oxygen.  Prolonged 
residence,  especially  during  the  winter  months,  in  a  warm, 
dry  climate  is  of  great  importance. 

Acute   uraemia  with   contracted  arteries  requires  arterial 


CHRONIC  j:  RIG  I  IT'S  DJSEASK.  583 

dilators,  such  as  nitroglycerin,  chloral  hydrate,  opium,  and 
potassium  iodide,  or  bloodletting. 

In  chronic  uraemia,  with  delirium,  stupor,  and  a  feeble 
heart,  we  employ  the  hot  pack,  heart-stimulants,  and  cathar- 
tics, but  the  results  are  not  usually  satisfactory. 

During  the  acute  exacerbation  the  patient  should  be  put 
to  bed  on  a  milk  diet  and  treated  as  if  he  had  acute  nephritis. 
Between  the  exacerbations  plenty  of  outdoor  life  in  fresh 
warm  air  may  be  advised,  but  not  to  the  point  of  fatigue. 

Chronic  Diffuse  Nephritis  without  Exudation. 

Etiolog-y  and  Synonyms. — This  disease  usually  occurs 
in  those  over  twenty  years  of  age.  It  may  appear  in  adults 
in  a  primary  form  as  a  gradual  degeneration  of  the  kidney ; 
it  often  runs  in  families  having  a  tendency  to  degeneration 
of  the  arteries.  It  may  be  caused  by  chronic  alcoholism, 
lead-poisoning,  gout,  excessive  eating  and  drinking,  lithae- 
mia,  and  constitutional  syphilis.  These  causes  are  also 
factors  in  causing  emphysema,  endocarditis,  endarteritis, 
and  cirrhosis  of  the  liver,  with  which  diseases  the  nephritis 
is  often  associated.  This  form  of  nephritis  also  follows 
chronic  congestion  of  the  kidney,  hydronephrosis,  and 
chronic  pyelitis.  Synonyms :  Chronic  interstitial  nephritis  ; 
Cirrhosis  of  the  kidney ;  Granular  kidney ;  Atrophic  form 
of  chronic  diffuse  nephritis  ;  Gouty  kidney  ;  Renal  sclero- 
sis ;  Arterio-sclerotic  kidney. 

Pathology. — The  kidneys  are  diminished  in  size ;  the 
capsules  are  adherent ;  the  surfaces  are  granular ;  the  cortex 
is  thinned  and  of  a  red  or  gray  color.  There  may  be  small 
cysts  on  the  surface.  Rarely  the  kidney  is  normal  or  even 
increased  in  size.  The  following  microscopical  changes  are 
described  by  Delafield  :  "  There  is  a  growth  of  new  connec- 
tive tissue  in  the  cortex,  and  also  in  the  pyramids,  which 
becomes  more  and  more  marked  as  the  disease  goes  on. 
In  the  cortex  the  new  tissue  follows  the  distribution  of  the 
normal  subcapsular  areas  of  connective  tissue,  is  in  the  form 
of  irregular  masses,  or  is  distributed  diffusely  between  the 
tubes.     In  the  pyramids  the  growth  of  new  connective  tissue 


584        J/.I.VC.IL    OF    THE   I'RACTICE    OF  MFDICI.XE. 

is  diffuse.  The  tubes,  both  in  the  cortex  and  in  the  pyra- 
mids, undergo  marked  changes.  Those  included  in  the 
maisses  of  connective  tissue  are  diminished  in  size ;  tlieir 
epithehum  is  flattened ;  some  contain  cast  matter,  many  are 
obhterated.  The  tubes  between  the  masses  of  new  connec- 
tive tissue  are  more  or  less  dilated ;  their  epithelium  is  flat- 
tened, cuboidal,  swollen,  degenerated,  or  fatty.  The  dilata- 
tion of  the  tubes  may  reach  such  a  point  as  to  form  cysts 
of  some  size  which  contain  fluid  or  coagulated  matter. 
Tiiese  cysts  follow  the  lines  of  groups  of  tubes  or  are  situ- 
ated near  the  capsules.  Of  the  glomeruli,  a  certain  number 
remain  of  normal  size,  but  with  the  tuft-cclls  swollen  or 
multiplied.  Many  others  are  found  in  all  stages  of  atrophy 
until  they  are  converted  into  little  fibrous  balls.  The  atro- 
phy seems  to  depend  partly  on  the  growth  of  tuft-cells  and 
intercapillary  cells,  partly  on  the  thickening  of  the  capsules, 
partly  on  the  occlusion  of  the  arteries.  If  the  chronic 
nephritis  follows  chronic  congestion,  the  glomeruli  remain 
large,  but  with  a  marked  growth  of  tuft-cells  ;  or  they  be- 
come atrophied,  but  with  the  dilatation  of  the  capillaries 
still  evident.  The  capillaries  of  the  glomeruli  may  be  the 
seat  of  a  waxy  degeneration.  The  arteries  exhibit  the  same 
changes  as  are  found  in  chronic  exudative  nephritis." 

Complicating-  Lesions. — Hypertrophy  of  the  left  ventri- 
cle of  the  heart  is  almost  constant,  and  affords  corroborative 
aid  in  diagnosis.  The  hypertrophy  may  be  followed  by 
dilatation,  chronic  degeneration,  or  myocarditis. 

General  arterio-sclerosis  is  frequently  found  associated 
with  the  nephritis.  Chronic  endocarditis  may  complicate 
the  disease.  In  some  cases  the  heart-lesion  is  primary, 
being  followed  by  chronic  congestion  of  the  kidney  and  by 
nephritis.  In  other  cases  the  cardiac  and  renal  changes 
occur  together  in  the  same  patient  and  are  due  to  the  same 
causes,  but  are  not  directly  dependent  on  each  other. 

Endarteritis  with  h)'pertrophy  of  the  heart  may  give  rise 
to  cerebral  hemorrhage. 

Emphysema  and  cirrhosis  of  the  liver  may  be  found  asso- 
ciated with  the  nephritis,  all  being  types  of  chronic  produc- 
tive inflanmiation  due  to  the  same  causes. 


CHRONIC   /!A'/C//7\S   D/SI-IASE.  585 

Pericarditis  is  not  uncommon,  and  should  be  suspected 
in  all  nephritis  cases  dangerously  sick  with  obscure  symj)- 
toms.  There  seems  to  be  an  increased  liability  to  gastritis 
and  bronchitis. 

Symptoms. —  i.  Urinary. — The  urine  is  usually  increased 
in  quantity,  is  of  a  light-yellow  color,  has  a  specific  gravity 
ranging  between  1005  and  loio.  and  contains  a  diminished 
amount  of  urea  to  the  ounce.  Albumin  and  casts  are  usu- 
ally absent,  or  albumin  is  present  only  in  traces,  especially 
in  the  early  morning  urine.  During  the  acute  exacerbations 
of  the  nephritis,  or  in  the  latter  stages  when  the  heart  be- 
gins to  fail,  albumin  and  casts  may  be  present  in  consider- 
able quantities.  In  exceptional  cases  the  specific  gravity 
may  be  normal,  or  it  may  be  exceedingly  low,  ranging  be- 
tween 1 00 1  and  1003,  with  or  without  waxy  degeneration 
of  the  vessels.  During  the  acute  exacerbations  of  the 
nephritis  and  during  the  attacks  of  contraction  of  the  arteries 
the  urine  may  be  scanty  or  even  suppressed.  In  rare  cases 
there  may  be  blood  in  the  urine,  or  even  profuse  bleeding 
from  the  kidneys. 

2.  Cerebral  symptoms  appear  in  the  majority  of  the  cases, 
and  are  due  to  a  variety  of  causes  : 

(rt)  Headache,  usually  frontal,  and  sleeplessness  are  com- 
mon ;  the  headache  may  be  so  severe  that  the  patient  is 
almost  beside  himself  There  may  be  in  various  parts  of 
the  body  neuralgic  pains  difficult  of  relief  Muscular  twitch- 
ings  and  general  convulsions  are  of  serious  import.  There 
may  be  delirium,  mild  or  furious,  or  stupor  and  coma. 
When  these'cerebral  symptoms  come  in  attacks  the  arteries 
are  contracted,  the  heart's  action  is  labored,  and  the  temper- 
ature is  raised.  To  this  condition  the  name  "  acute  uraemia  " 
is  given.  From  such  an  attack  the  patient  may  die,  or  he 
may  recover,  but  the  attack  is  liable  to  be  repeated.  These 
attacks  may  occur  early  or  late  in  the  disease,  and  such  an 
attack  may  even  be  the  first  symptom  noticed. 

iU)  Delirium  and  stupor  may  come  on  gradually  in  the 
latter  part  of  the  disease,  with  a  feeble,  low-tension  pulse 
and  a  tendency  to  a  subnormal  temperature.  These  symp- 
toms are  due  to  chronic  uremia. 


586      M.ix(.:ii.  OF  J7/J-:  pa'.ictjce  of  mfdicixe. 

(r)  There  ma\'  be  the  sx-niptimis  of  cerebral  lieiiiorrhage, 
coma,  hemiplegia,  and  possibly  of  aphasia. 

(</)  There  may  be  attacks  of  hemiplegia  or  aphasia,  with 
coma  which  may  persist  until  death  or  disappear  in  a  lew 
da\'S.  These  symptoms  appear  to  be  due  to  endarteritis  of  the 
cerebral  vessels,  and  not  to  an\'  changes  in  the  brain-tissue. 

3.  Circulatory  Symptoms. — The  pulse  is  hard  and  of  an 
increased  tension.  Thickening  of  the  arterial  wall  from 
endarteritis  may  render  the  artery  less  compressible,  and 
should  not  be  mistaken  for  an  actual  increase  in  tension. 
A  low-tension  pulse  is  not  a  favorable  symptom.  The  left 
ventricle  is  almost  invariably  found  hypertrophied,  and  the 
second  aortic  soiind  is  accentuated.  Should  dilatation  or 
heart-weakness  occur,  the  pulse  will  fall  in  tension  and 
signs  of  venous  congestions  will  appear,  so  that  the  con- 
dition will  resemble  that  of  a  chronic  heart-lesion.  A  great 
deal  can  be  done  by  appropriate  treatment  to  prevent  dila- 
tation from  occurring. 

4.  Respiratory  Symptoms. — Dyspnoea  is  frequently  the 
first  symptom  noticed,  appearing  in  spasmodic  attacks 
aggravated  by  exertion  or  by  the  recumbent  position.  The 
attacks  may  last  for  minutes,  hours,  or  days.  The  spas- 
modic dyspnoea  appears  to  be  due  to  an  association  of  con- 
tracted arteries  with  a  feeble  or  dilated  heart.  Dyspnoea 
more  or  less  steady  may  also  be  due  to  chronic  uraemia, 
anaemia,  pleural  effusion,  or  pericarditis.  There  may  be 
Cheyne-Stokes  breathing  toward  the  close  of  the  disease — 
a  most  unfavorable  symptom.  Bronchitis,  especially  dur- 
ing the  winter,  is  exceedingly  common;  pleurisy  and  pneu- 
monia are  not  uncommon.  There  may  be  sudden  oedema 
of  the  glottis  or  of  the  lung,  especially  during  acute  urajmic 
attacks.  Emphysema  frequently  coexists  and  adds  its  symp- 
toms to  the  clinical  history. 

5.  G astro-intestinal  Symptoms. — There  may  be  attacks  of 
catarrhal  gastritis  or  of  spasmodic  vomiting,  which  may  be 
severe  and  uncontrollable,  endangering  the  life  of  the  patient. 
Loss  of  appetite  and  dyspeptic  symptoms  are  common. 
There  may  be  severe  diarrhcea,  which  to  a  certain  extent 
appears  to  be  compensatory,  aiding  in  the  elimination  of  the 


CHRON/C   URfCI/T'S   D/SEASE.  587 

urea,  and   therefore   it  should  not  be   eheeked  too   rapidly 
unless  it  be  excessive  and  exhausting. 

6.  Special  Senses. — Sudden  blindness — "  uraemia  amauro- 
sis " — may  occur  without  retinal  changes,  and  may  be 
temporary  or  permanent.  Neuro-retinitis  or  retinitis  albu- 
minurica,  with  white  specks  and  flame-shaped  hemorrhages, 
with  or  without  thickening  of  the  retinal  vessels,  may  occur 
as  the  initial  symptom,  and  many  cases  of  nephritis  are 
often  first  diagnosed  by  the  ophthalmologist,  to  whom  the 
patient  applies  for  relief  from  the  troubles  in  vision.  Ring- 
ing in  the  ears  with  dizziness  is  not  uncommon,  and  deaf- 
ness may  occur. 

7.  Skin. — There  may  be  some  puffiness  of  the  ankles 
from  time  to  time,  but  this  symptom  is  not  common,  and 
dropsy  does  not  occur  unless  it  be  the  result  of  a  failing 
heart.  The  skin  is  usually  dry,  and  sweating  is  not  com- 
mon. In  bad  cases  of  uraemia  urea  may  be  excreted,  giving 
a  frosted  appearance  to  the  skin.  There  may  be  purpura  in 
cachectic  conditions. 

.  8.  General  Condition. — The  blood  becomes  anaemic,  but 
this  is  not  as  marked  as  in  the  cases  with  exudation.  The 
nutrition  is  affected,  so  that  there  is  a  gradual  loss  of  flesh 
and  of  strength. 

Course  of  the  Disease. — At  autopsy  from  some  intercur- 
rent disease  the  lesion  may  be  found  in  a  fairly  advanced 
form  without  having  given  appreciable  symptoms  during 
the  life  of  the  patient. 

2.  Some  patients  go  for  years  with  a  urine  of  low  specific 
gravity,  with  a  hypertrophied  left  ventricle,  with  accentuated 
second  aortic  sound,  and  with  habitual  increase  of  arterial 
tension,  and  yet  feel  perfectly  well.  Upon  these  symptoms, 
however,  a  diagnosis  can  with  certainty  be  made.  Any 
persistent  high  tension  of  the  pulse  with  thickening  of  the 
arterial  wall  in  a  patient  under  fifty  years  of  age  points  to 
cardio-vascular,  and  pi'obably  to  renal,  changes. 

3.  There  may  be,  from  time  to  time,  attacks  of  acute 
uraemia,  with  contracted  arteries,  increased  blood-tension, 
and  cerebral  symptoms.  The  urine  is  scant}'  and  contains 
albumin.      Each  succeeding  attack  is  apt  to  be  more  severe. 


588        M.-iXC.lL    OF   THE   PRACTICE    OF  MEDICIXE. 

and  between  the  attacks  the  general  health  depreciates  and 
the  patient  becomes  feeble  and  emaciated. 

4.  There  may  be  no  symptoms  for  a  long  time,  the  first 
evidence  of  disease  being  an  attack  of  acute  uraemia  from 
which  the  patient  nia\-  or  ma\'  not  recover,  or  of  cerebral 
endarteritis  or  cerebral  hemorrhage. 

5.  In  some  cases  a  gradual  loss  of  flesh  and  of  strength 
with  digestive  disturbances  and  low  specific  gravit)-  of  the 
urine  may  be  the  only  symptoms  until  the  time  of  the 
patient's  death.  The  only  .symptom  pointing  to  the  kidney 
is  the  low  specific  gravity  of  the  urine. 

6.  The  kidney-lesion  may  give  no  direct  symptoms ;  but 
should  the  hypertrophied  heart  begin  to  dilate  and  nervous 
congestion  appear,  the  picture  will  be  that  of  the  last  stages 
of  heart  disease,  and  the  primary  kidney-lesion  will  be  over- 
looked. Many  of  the  so-called  cases  of  "idiopathic  dilata- 
tion "  arise  in  this  way. 

Prognosis. — The  disease  is  absolutely  incurable,  but  it  is 
not  incompatible  with  the  enjoyment  of  a  busy  life  for  a 
number  of  years.  Cases  have  been  followed  for  ten  or 
fifteen  years.  Much  depends  upon  how  much  care  the 
patient  will  take  of  himself,  and  how  carefully  dilatation 
and  heart-failure  are  guarded  against. 

Treatment. — General  Treatment. — Much  good  can  be 
done  by  regulating  the  diet  and  the  mode  of  life  and  by 
selecting  a  suitable  climate.  The  diet  should  be  light  and 
nourishing,  but  not  excessive.  Meat  should  be  taken  but 
once  a  day,  but  the  ingestion  of  fats  should  be  encouraged. 
Alcohol  should  be  prohibited ;  tea  and  coffee  may  be 
allowed  in  moderation.  The  urinary  secretion  should  be 
kept  free  by  drinking  a  certain  amount  of  distilled  water  or 
some  mineral  water  like  Poland.  The  bowels  should  be 
kept  freely  open  ;  the  skin  is  to  be  kept  active  by  daily  baths 
and  friction  ;  and  exercise  in  the  open  air  should  be  encour- 
aged in  proportion  to  the  strength.  Much  is  gained  by 
spending  the  winter  months  in  some  warm,  equable  climate. 
Severe  mental  or  physical  work  should  be  avoided,  so  as  to 
lessen  the  strain  on  the  heart  and  the  arteries.  Anaemia  i.? 
to  be  treated  by  iron. 


WAXY  BEGENEKAriON  OF   TJJE   KIDNEY.  589 

Heart  and  Arteries. — A  certain  increase  in  tension  is 
allowable.  Excessive  tension  should  be  reduced  by  an 
occasional  saline  laxative  and  hot  bath.  Of  the  arterial 
dilators,  the  best  are  nitroglycerin  (gr.  yJ-Tj-  three  times  a 
day,  increased,  if  necessary,  until  the  desired  effect  is  pro- 
duced), potassium  iodide  (gr.  x  three  times  a  day),  and 
chloral  hydrate  (gr.  v-viij  three  times  a  day).  Not  only  is 
the  tension  thus  reduced,  but  headache,  dizziness,  and  dysp- 
noea are  often  relieved  in  a  most  satisfactory  manner.  For 
restlessness  morphia  in  small  doses  at  night  may  be  used. 
Should  the  heart's  power  fail  and  the  tension  be  low,  .stimu- 
lants are  needed  as  in  cardiac  disease — caffeine,  digitalis, 
strychnine,  and  strophanthus.  Opium  is  contraindicated 
in  these  cases,  as  small  doses  frequently  cause  fatal  poi- 
soning. 

UrcEinia. — Acute  uraemia  being  due  to  contracted  arteries, 
arterial  dilators  are  indicated  in  free  doses.  The  bowels 
should  be  opened  rapidly,  and  in  case  of  convulsion  or 
coma  bloodletting  is  frequently  followed  by  brilliant  results. 
Hypodermic  injections  of  from  ^  to  ^  grain  of  morphia  may 
be  used  in  convulsions  or  coma  with  benefit,  and  for  the 
convulsions  whiffs  of  chloroform  may  be  needed. 

Chronic  uraemia  being  due  to  retention  of  excrementitious 
substances,  effort  should  be  made  to  increase  their  elimina- 
tion. The  kidneys  should  be  stimulated  by  digitalis  com- 
bined with  the  saline  diuretics ;  cups  and  poultices  over  the 
kidneys  should  be  employed  in  bad  cases.  The  bowels 
should  be  opened  energetically,  and  sweating  is  to  be  in- 
duced by  the  hot  pack  or  the  hot-air  bath. 

Acute  exacerbations  should  be  treated  on  the  lines  laid 
down  for  acute  nephritis. 


WAXY    DEGENERATION    OF    THE    KIDNEY 
(AMYLOID    KIDNEY). 

Waxy  degeneration  of  the  kidney  does  not  appear  as  a 
disease  by  itself,  but  as  an  added  degeneration  to  the  lesions 
of  chronic  diffuse  nephritis,  usually  of  the  form  with  exuda- 
tion.    It  occurs  in  cases  with  prolonged  suppuration,  espe- 


59©        M.t.vr.lL    OF   THE   PRACTICE    OF  MEDICIXE. 

ciall)'  of  the  bones,  with  syphihs  and  tuberculosis,  occa- 
sionall)'  with  leukii:niia,  and  in  rare  cases  without  apparent 
cause.  It  is  associated  with  ani}  loid  det^eneration  of  the 
spleen  and  the  liver. 

Pathology. — There  are  usually  the  appearances  of  the 
"  large  white,"  more  rarely  of  the  "  small  white,"  kidney. 
The  glomeruli  are  distinct  and  have  a  bacon-like  kustre, 
staining  mahogany-brown  with  weak,  watery  solutions  of 
iodine,  and  red  with  dilute  solutions  of  methyl-violet.  The 
amyloid  degeneration  involves  the  vessels  of  the  glomeruli, 
of  the  vasa  recta,  and  occasionally  of  the  membrane  of  the 
uriniferous  tubules. 

Symptoms. — The  urine  is  usually  abundant,  pale,  and  of 
a  low  specific  gravity.  Albumin  is  usualh'  present  in  con- 
siderable quantity,  and  there  may  be  globulin.  Tube-casts 
frequently  include  hyaline  varieties  which  give  the  amyloid 
reaction.  The  general  .symptoms  are  those  of  the  associated 
nephritis,  together  with  the  original  suppurative  or  cachectic 
disease  to  which  the  amyloid  changes  are  secondary.  The 
diagnosis  is  aided  by  the  detection  of  waxy  changes  in  the 
liver  and  the  spleen. 

TUBERCULAR    DISEASES    OF    THE    KIDNEY. 

Tuberculosis  of  the  Kidney. 
Miliary  tubercles  are  frequently  found  in  the  kidney  in 
cases  of  general   miliary  tuberculosis.      The  tubercles  are 
small,  are   unaccompanied   by  inflammatory  changes,   and 
do  not  give  rise  to  symptoms. 

Tubercular  Pyelonephritis. 
Etiology. — The  tubercle  bacilli  may  infect  the  kidney 
through  either  the  blood-vessels  or  the  urinary  passages. 
The  infection  may  in  rare  instances  be  primary,  but  the 
ordinary  cases  are  secondary  to  a  tubercular  focus  else- 
where, especially  in  the  bladder,  the  prostate,  or  the  seminal 
vesicles.  In  many  cases  it  is  impossible  to  .say  whether  a 
primary  tuberculosis  of  the  kidney  has  been  followed  by 
secondary  tubercular  lesions  in  the  genito-urinary  tract,  or 


rUBKRCUf.AK   DISEASES    OF    ■n/J':    KIDNEY.  59! 

whether  the  kidney-lesions  have  followed  infection  creeping 
up  the  ureters  from  a  primary  focus  below. 

Tubercular  disease  of  the  kidney  is  twice  as  frequent 
in  men  as  in  women,  and  it  is  most  frequent  in  those  of 
middle  age. 

Patholog-y. — The  lesion  usually  begins  in  the  pelvis  of 
the  kidney.  The  pelvis  becomes  dilated  and  is  filled  with 
pus  and  cheesy  material ;  its  walls  are  thickened,  infiltrated 
by  pus  and  tubercle-tissue,  and  its  mucosa  becomes  increased 
in  thickness.  Tubercular  infiltration  extends  to  the  kidney- 
tissue  and  rapidly  undergoes  cheesy  degeneration  and  soften- 
ing, so  that  the  kidney  becomes  honeycombed  with  cavities. 
In  advanced  cases  the  kidney  is  converted  to  a  cyst  contain- 
ing inspissated  cheesy  matter  infiltrated  with  lime-salts.  Both 
kidneys  are  usually  involved,  but  the  disease  is  usually 
more  advanced  on  one  side  than  on  the  other.  In  other 
cases  one  kidney  alone  is  involved,  the  kidney  of  the  oppo- 
site side  developing  the  lesions  of  chronic  diffuse  nephritis 
with  exudation  usually  with  waxy  changes. 

In  the  majority  of  cases  tubercular  disease  of  the  kidney 
is  complicated  by  similar  tubercular  changes  in  the  ureter 
and  the  bladder,  and  sometimes  in  the  prostate  gland  and 
the  seminal  vesicles  as  well. 

Symptoms. —  i.  Urinary  symptoms  consist  in  the  fre- 
quent appearance  in  the  urine  of  pus,  cheesy  material,  fatty 
epithelial  cells,  and  shreds  of  kidney-tissue.  There  may 
be  occasional  admixture  of  blood.  These  urinary  changes 
also  occur  with  calculous  pyelo-nephritis,  and  so  possess  no 
absolutely  diagnostic  value.  The  discovery  of  tubercle 
bacilli,  however,  in  the  urine  is  an  infallible  sign  of  tuber- 
culosis. The  bacilli  are  best  found  in  the  small  particles 
of  cheesy  matter  present  in  the  sediment.  Albuminuria  is 
usually  more  marked  than  can  be  accounted  for  by  the  pus. 
Tube-casts  are  of  rare  occurrence. 

2.  Local  symptoms  consist  of  pain  and  tenderness  over  the 
affected  kidney.  The  pain  may  be  dull  and  continuous  or 
it  may  be  paroxysmal,  resembling  renal  colic ;  in  the  latter 
case  it  is  due  to  the  passage  of  lumps  of  cheesy  material 
aloncr  the  ureter. 


59^      M.ixr.iL  OF  THE  practice  of  MEDICrXE. 

3.  An  enlargement  of  the  kidney  may  be  appreciated  in 
some  instances,  as  in  calculous  or  suppurative  p>-onephritis, 
but  as  the  enlargement  is  rarely  decided,  it  is  with  diffi- 
culty detected. 

4.  The  co)istitiitio)ial  symptouis  are  those  of  other  tuber- 
cular diseases.  Fever  is  rarely  absent,  and  usually  presents 
a  remitting  hectic  character.  Ana:mia,  emaciation,  and 
weakness  increase  with  the  progress  of  the  disease. 

5.  There  may  be  complicating  tubercular  diseases  else- 
where which  add  their  characteristic  symptoms.  Acute 
miliary  tuberculosis  not  infrequently  develops. 

Diagnosis. — The  diagnosis  from  calculous  pyelonephritis 
is  made  (i)  by  the  presence  of  tubercular  disease  elsewhere, 
especially  in  the  lower  genito-urinary  organs  ;  (2)  by  the 
absence  of  a  history  of  renal  calculi ;  (3)  by  the  presence 
of  the  tubercle  bacilli  in  the  urine. 

Prognosis. — The  course  of  the  disease  is  progressive. 
The  great  majority  of  cases  terminate  fatally  within  two 
years,  but  it  is  possible  for  the  disease  to  stop  and  the 
patient  to  recover. 

Treatment. — Surgical  treatment  consists  in  the  removal 
of  the  diseased  kidney,  and  this  should  be  done  before  other 
portions  of  the  genito-urinary  tract  become  infected;  hence 
an  early  diagnosis  is  of  the  greatest  importance,  and  it 
should  be  a  rule  to  examine  for  tubercle  bacilli  in  every 
case  of  persistent  pyuria,  so  that  incipient  cases  of  tubercular 
kidney  may  thus  be  recognized. 

SUPPURATIVE    DISEASE    OF    THE   KIDNEY 

(SURGICAL   KIDNEY). 
• 
Etiology. — The  germs  of  suppuration  may  gain   access 

to  the  kidney — (i)  through  the  abdominal  wall,  as  with 
penetrating  wounds ;  (2)  by  extension  from  neighboring 
abscesses  ;  (3)  through  the  blood-vessels,  as  in  pyaemia  and 
malignant  endocarditis  ;  and  (4)  through  the  ureter,  as  from 
cystitis  or  following  operations  upon  the  genito-urinary 
organs.  The  first  two  methods  of  infection  are  exceedingly 
rare.  Infection  through  the  ureter  is  favored  by  inflam- 
matory   conditions    of   the    urinary    passages,    by    pyelitis, 


SUPPURATJl-E    DrSEASE    OJ'    'J'lIE    KIDNEY.  593 

whether  simple,  tubercular,  or  calculous,  and  by  injuries 
and   contusions  of  the  kidney. 

Suppuration  of  the  kidney  alone  is  termed  "  suppurative 
nephritis,"  but  as  the  pelvis  of  the  kidney  is  almost  regularly 
involved,  the  name  "  pyelo-nephritis "  is  often  applied. 
Should  the  pelvis  of  the  kidney  be  distended  with  pus,  the 
term  "  pyonephrosis  "  is  not  inappropriately  applied. 

The  cases  of  suppurative  pyelo-nephritis  complicating 
tubercular  disease  and  calculi  in  the  pelvis  of  the  kidney 
will  be   considered  when   discussing  these  diseases. 

Pathology  and  Symptoms. —  i.  Abscesses  produced  by 
emboli  may  occur  in  the  course  of  pyaemia  and  malignant 
endocarditis.  Both  kidneys  are  large,  congested,  and 
studded  with  small  abscesses.  The  blocking  of  small  ter- 
minal arteries  by  the  emboli  causes  pyramidal  areas  of  white 
infarctions  which  subsequently  break  down  to  form  abscesses. 

The  symptoms  of  embolic  abscesses  in  the  kidney  are 
obscured  by  those  of  the  primary  disease.  Pus  may  not 
appear  in  the  urine,  as  the  abscesses  seldom  communicate 
with  the  urinary  tubules. 

2.  Idiopathic  abscesses  occur  without  assignable  cause, 
and  it  is  unknown  whether  the  suppuration  begins  first  in 
the  kidney  or  in  its  pelvis.  One  kidney  becomes  partially 
destroyed,  and  in  the  remaining  portion  abscesses  are  found. 
The  pelvis  of  the  kidney  is  inflamed  and  becomes  dis- 
tended with  pus,  constituting  a  pyonephrosis.  The  sup- 
purative processes  may  extend  to  the  perinephritic  tissues. 

The  symptoms  are  at  first  obscure : 

{a)  Pus-symptoms  are  present,  consisting  of  irregular 
fever,  erratic  chills,  and  cold  sweatings.  The  symptoms  of 
septicsemia  or  of  the  typhoid  condition  may  become  marked, 
or  the  patient  will  develop  the  waxy  changes  in  the  viscera 
that  regularly  accompany  prolonged  suppuration. 

{h)  Symptoms  of  a  localized  abscess  consist  of  pain  and 
tenderness  over  the  kidney. 

(r)  Pus  and  broken-down  kidney-tissue  are  present  in  the 
urine.  The  urine  is  frequently  acid,  the  pus  is  uniformly 
mixed  with  the  urine,  and  the  character  of  the  urine  is 
unchaneed  after  the   bladder  has  been  washed  out.     From 


594        M.lXr.lL    OF   THE   PA'ACT/CE    OF  J/FD/C/.VF. 

time  to  time  the  pus  escapes  fiDin  the  dilated  i)el\-is  in  large 
quantities  and  appears  in  the  urine. 

,  (</)  There  may  be  a  tumor,  appreciable  by  palpation 
should-  the  pelvis  of  the  kidney  be  sufficiently  distended 
by  pus.  The  tumor  may  become  reduced  in  size  by  the 
escape  of  pus  in  large  quantities  down  the  ureters. 

3.  Sitppiirath'i'  Pyelonephritis  froui  Cystitis. — Both  kidneys 
are  swollen,  congested,  and  studded  with  small  foci  of  in- 
flammation. The  pelvis  of  the  kidney  is  inflamed  and 
coated  with  fibrin  and  pus.  By  the  confluence  of  the  sup- 
purative foci  large  portions  of  the  kidne\'s  are  con\erted  to 
abscesses.  The  ureters  may  be  normal  or  they  may  be 
inflamed.  The  lesions  of  an  acute  or  chronic  cystitis  are 
almost  alwa}-s  present. 

In  some  cases  there  is  an  antecedent  history  of  cystitis. 
At  the  time  of  the  kidney-infection,  the  patient  will  develop 
septic  symptoms — repeated  chills  and  irregular  fever  with 
prostration.  The  urine  will  be  diminished  and  will  contain 
pus  and  blood  from  the  bladder  or  kidney  or  from  both.  In 
some  cases  the  urine  is  altogether  suppressed.  Prostration 
becomes  more  extreme,  and  the  patient  dies  with  pyemic 
or  septic  symptoms. 

4.  According  to  Delafield,  suppurative  nephritis  following 
cystitis  due  to  enlarged  prostate  presents  a  different  clini- 
cal picture.  The  patients  are  men,  usually  over  fifty  years 
of  age,  who  have  suffered  from  cystitis  and  an  enlarged 
prostate  gland.  The  first  symptom  is  a  diminished  quan- 
tit\'  of  urine  containing  blood,  or  blood  alone  may  seem  to 
be  passed.  In  other  cases  the  urine  is  altogether  suppressed. 
The  patient  becomes  restless,  anxious,  and  shows  an  increas- 
ing prostration  ;  there  are  usually  no  chills,  and  there  may 
be  no  fever.  The  patient  may  either  die  in  collapse  within 
a  few  days  or  may  die  from  septic  poisoning. 

The  prognosis  is  always  fatal  if  both  kidne\'s  be  involved. 
If  one  kidney  alone  be  the  seat  of  abscess,  it  may  be  removed 
and  the  patient  may  recover. 

Treatment. — The  preventive  treatment  is  directed  toward 
the  cystitis  and  toward  strict  asepsis  in  all  operaticjns  uj^on 
the    urinary    organs.       When    symptoms    of    suppurative 


'J'UiMUKS    OP-    'J'JJE    KJJJNEY.    .  595 

nephritis  occur,  it  is  of  the  greatest  importance  to  decide 
whether  one  or  both  kidneys  be  involved.  The  position 
of  localized  tenderness  is  to  be  considered,  but  the  surest 
method  of  settling  the  question  is  by  cystoscopic  examina- 
tion. If  by  the  cystoscope  purulent  urine  be  seen  to  flow 
from  both  ureters,  operative  treatment  is  of  no  avail.  If  the 
pus  be  seen  to  flow  from  one  ureter  alone,  the  prospects  of 
recovery  after  the  operation  are  rendered  more  probable. 

TUMORS   OF   THE   KIDNEY. 

Benign  tumors  consist  of  fibroma,  lipoma,  lym.phade- 
noma,  and  adenoma.  These  benign  growths  are  of  little 
clinical  interest. 

Malignant  tumors  are  sarcoma  and  carcinoma. 

Sarcoma  may  occur  in  adult  life,  but  it  is  more  frequent 
in  young  children,  and  not  infrequently  it  occurs  as  a  con- 
genital tumor.  The  ordinary  form  of  sarcoma  is  the  small- 
celled  variety  ;  a  rarer  form,  usually  of  congenital  origin,  is 
the  rhabdo-myoma,  which  consists  of  sarcoma  and  striped 
muscular  fibre.  Sarcoma  of  the  kidney  grows  rapidly,  is 
very  vascular,  and  frequently  breaks  down  in  places  to  form 
cysts  containing  blood  and  clots. 

Carcinoma  is  usually  of  the  encephaloid  variety,  and  so 
frequently  shows  an  alveolar  structure  that  it  has  been 
described  as  "  malignant  adenoma." 

Secondary  cancer  of  the  kidney  is  not  uncommon,  with 
a  primary  growth  situated  in  the  testicle  or  the  prostate 
gland.  In  the  secondary  form  both  kidneys  are  usually 
studded  with  small  isolated  nodules. 

Primary  malignant  growths  of  the  kidney  frequently  reach 
enormous  dimensions,  so  as  to  cause  symptoms  by  pressure 
upon  the  abdominal  organs.  Pressure  on  the  ureter  fre- 
quently results  in  a  hydronephrosis.  Secondary  deposits 
may  occur  by  extension  or  metastasis. 

Symptoms  consist  of  pain  and  tenderness,  haematuria,  can- 
cerous cachexia,  and  the  presence  of  an  abdominal  tumor. 

Pain  and  tenderness  are  not  constantly  present.  The 
pain  may  be  steady  and  dull,  radiating  to  the  groin  and  the 
thigh,  or  there  may  be  a  paroxysmal  pain,  due  to  the  pass- 


596        M.lXf.lI.    OF   Till:    PRACriCE    OF  MEDICINE. 


age  of  a  blood-clot  down  the  ureter,  resembling  the  pain 
of  renal  colic. 

HcCDiaturia  occurs  in  about  half  the  cases,  and  may  be 

the  first  symptom  noticed. 
The  blood,  when  present, 
is  usually  constant.  There 
may  be  blood-casts  of  the 
pelvis  of  the  kidney  and 
of  the  ureter;  these  casts 
are  \er)'  characteristic  of 
cancer.  The  blood  is 
usuall)'  ])assed  in  small 
quantities,  although  ex- 
hausting or  even  fatal 
hemorrhages  may  occur. 
The  symptoms  of 
Dial iii  II nil/  cachexia  be- 
come progressively 
marked.'  Anaemia  is 
rendered  more  profound 
by  the  occurrence  of 
hemorrhage ;  emaciation 
is  extreme,  and  is  in 
marked  contrast  to  the 
enlarged  abdomen. 
The  tumor  is  at  first  located  in  the  region  of  the  kidney, 
but  it  tends  later  to  invade  the  whole  abdominal  cavity.  It 
may  be  distinguished  by  the  following  peculiarities  :  {a)  The 
surface  often  presents  a  series  of  convexities  or  knobs  ;  {b) 
there  is  no  respiratory  movement  of  the  growth,  and  {c)  the 
hand  may  usually  be  thrust  between  it  and  the  free  border 
of  the  ribs ;  {d)  the  growth  is  not  movable,  as  is  a  floating 
kidney ;  (e)  percussion  shows  the  colon  passing  in  front  of 
the  growth ;  {/)  a  tympanitic  zone  is  usually  detected  by 
percussion  between  the  liver  and  the  neoplasm ;  {g)  rapid- 
growing  tumors  may  yield  a  sense  of  fluctuation;  [Ji)  the 
renal  tumor  can   usually  be  traced  deeply  into  the  loin. 

In  children  the  diagnosis  of  the  growth  from  retroperito- 
neal sarcoma  may  be  impossible. 


Fig.  50. — Sarcoma  of  kidney.     Perfect    HctIiIi 
after  operation  (Abbe). 


CKVZ'.V    OF    77//''.    /^'//JN/CV.  ^(jj 

The  duration  of  malignant  growths  of  the  kidney  is  vari- 
able. The  congenital  cases  may  terminate  fatally  within  a 
few  weeks  after  birth.  Usually  in  children  the  course  i.s 
more  rapid  and  malignant  than  in  adults,  seldom  extending 
over  one  year.  More  rarely  the  disease  may  exist  for  a 
number  of  years  before  death  occurs. 

The  prognosis  is  uniformly  bad  unless  an  early  and 
successful  nephrectomy  be  performed. 

Treatment. — The  results  of  nephrectomy  for  sarcoma  in 
children  are  not  good.  The  operation,  however,  should  be 
performed  if  the  diagnosis  be  made  early  in  the  disease,  and 
in  cases  in  which  the  disease  is  limited  to  the  kidne}-.  In 
adults  the  results  of  the  operation  are  somewhat  more  en- 
couraging. The  risks  of  the  operation  itself  are  great, 
shock  and  hemorrhage  being  the  imminent  dangers  en- 
countered. 

CYSTS    OP    THE    KIDNEY. 

Etiology  and  Pathology. — Small  rctcntion-cysts  of  the 
kidney  are  common  in  chronic  nephritis  ;  they  may  also 
occur  in  comparatively  healthy  kidneys. 

Congenital  Cystic  Kidney. — The  kidneys  are  enlarged 
and  are  converted  into  a  mass  of  cysts  of  all  sizes,  separated 
by  septa  of  connective  tissue  or  of  compressed  kidney- 
structure.  The  cysts  contain  a  clear  fluid  holding  the 
urinary  salts  in  solution,  or  the  fluid  may  be  brownish  and 
turbid.  Albumin,  blood,  uric-acid  crystals,  and  cholesterin 
are  often  found  in  these  cysts.  Congenital  cystic  kidney  is 
probably  the  result  of  defective  development,  but  how  the 
cysts  actually  originate  is  not  known. 

In  adults  multiple  cysts  may  be  found  in  the  kidneys. 
The  cysts  contain  clear  or  brownish  serum  or  colored 
matter.  Similar  cysts  are  sometimes  found  in  the  liver  and 
the  spleen.  The  origin  of  these  cysts  is  unknown,  although 
it  has  been  surmised  that  they  are  congenital. 

Symptoms. — Cysts  of  the  kidney  give  of  themselves  no 
characteristic  symptoms  except  in  rare  cases  of  rupture. 
Symptoms  of  chronic  diffuse  nephritis  are  usually  present, 
and  death  may  finally  result  from  uraemia. 

Treatment  is  useless. 


59^        J/./.\r./Z    OF   THE   PRACriCE    OF  MEDICIXE. 

PYELITIS. 

Etiology. — Inflaniniations  of  the  pelvis  associated  with 
suppuration  of  the  kitlney,  renal  calculi,  and  tubercular 
disease   have   elsewhere   been   described. 

Besides  these  forms,  pyelitis  may  develop  after  the  use  of 
turpentine,  cubebs,  and  cantharides,  and  from  the  irritation 
of  saccharine  or  deconiposinf,^  urine  within  the  pelvis. 
Secondary  p>'elitis  may  complicate  t\-phoid  fever,  diphtheria, 
and  the  exanthemata.  Chronic  catarrhal  pyelitis  may  result 
from  cystitis,  from  hydronephrosis,  or  from  the  continuance 
of  an  acute  attack.  In  some  cases  the  cystitis  may  develop 
without  apparent  cause. 

Patholog-y. — The  mucous  membrane  of  the  pelvis  is 
thickened,  infiltrated,  and  coated  with  mucus  or  with  muco- 
pus.  Phosphatic  calculi  may  form  as  the  result  of  the  in- 
flammation. In  some  cases  the  inflammation  spreads  to  the 
kidnc}',  so  that  a  pyelo-nephritis  results. 

Symptoms.  —  Pain  and  tenderness  are  referred  to  the 
kidney.  The  urine  is  generally  acid  in  reaction  and  con- 
tains pus,  mucus,  epithelial  cells  from  the  pelvis  of  the 
kidney,  and  occasionally  blood.  The  pyuria  ma}'  be  con- 
stant or  intermittent.  If  suppuration  extend  to  the  kidney 
itself,  the  symptoms  of  suppurative  pyelo-nephritis  or  of 
pyonephrosis  will  be  developed. 

The  diagnosis  from  tubercular  pyelo-nephritis  is  made 
by  the  absence  of  tubercular  foci  in  other  parts  of  the  body 
and  by  the  absence  of  tubercle  bacilli  in  the  urine.  The 
course  of  the  tubercular  form  of  pyelitis  is  more  serious, 
and  the  disease  usually  terminates  fatally.  The  diagnosis 
from  calculous  pyelitis  cannot  be  made  in  all  cases,  but  a 
long  history  of  renal  calculi  affords  an  important  clue  to  the 
diagnosis,  and  pyelitis  is  to  be  considered  calculous  if 
crystals  of  uric  acid  or  of  oxalate  of  lime  be  more  or  less 
continuously  present  in  the  urine. 

Treatment  consists  in  giving  bland  alkaline  mineral 
waters  or  citrate  of  potassium  in  doses  sufficient  to  render 
the  urine  neutral  in  reaction.  The  diet  should  be  unirritat- 
ing,  and  drugs  that  are  capable  of  causing  irritation  or  con- 


//  y  'D  R  OA'K/'IJN  os/s.  5  99 

gestion  of  the  kidney  sliould  not  be  given.     If  suppurative 
pyelo-nephritis  occur,  surgical  treatment  is  indicated. 

HYDRONEPHROSIS. 

Btiolog'y. — When  any  obstruction  arises  in  the  urinary 
tract,  interfering  with  the  free  passage  of  urine,  the  pent-up 
urine  causes  an  increasing  dilatation  of  the  urinary  parts 
above  the  contraction.  A  contraction  of  the  ureter  may 
result  from  impacted  renal  calculi,  from  bends,  from  cica- 
tricial contraction,  or  from  external  pressure,  especially  by 
new  growths  of  the  uterus  or  the  ovaries.  The  lower 
orifice  of  the  ureter  may  be  stenosed  in  cancer  of  the 
bladder.  In  some  cases  congenital  hydronephrosis  results 
from  congenital  membranous  obstruction  or  from  abnormal 
valve-formations  of  the  ureter.  Double  hydronephrosis, 
which  results  from  strictures  of  the  urethra,  may  also  occur 
with  enlargement  of  the  prostate  gland,  or  even  with 
phimosis.  Double  hydronephrosis  .  is  regularly  accom- 
panied by  dilatation  of  the  bladder  and  of  both  ureters. 
The  more  gradually  the  obstruction  is  developed,  the 
greater  the  degree  of  the  dilatation ;  and  it  is  important 
to  remember  that  a  sudden  complete  obstruction  of  a 
ureter,  as  by  a  renal  calculus,  does  not  lead  to  hydrone- 
phrosis, but  to  atrophy  of  the  kidney. 

Patholog-y. — The  pelvis  of  the  kidney  is  dilated ;  pres- 
sure-atrophy of  the  kidney-tissue  results,  and  in  the  com- 
pressed kidney  a  chronic  nephritis  is  set  up.  In  advanced 
cases  the  kidney  becomes  converted  to  a  cyst,  in  whose 
wall  may  be  seen  a  thin  rind  of  atrophied  and  com- 
pressed kidney-tissue.  The  fluid  is  thin  and  yellowish,  and 
contains  urea,  uric  acid,  and  sometimes  albumin.  It  may 
be  turbid  from  the  admixture  of  pus.  In  cases  of  long 
duration  the  urinary  salts  may  disappear,  so  that  the  fluid 
may  not  be  characteristic.  In  extreme  cases  the  sac  may 
contain  from  ten  to  twenty  quarts  of  fluid. 

Symptoras. — The  majority  of  cases  give  rise  to  no  symp- 
toms except  the  presence  of  a  tumor,  which  first  appears  in 
the  region  of  the  kidney  and  enlarges  toward  the  hypo- 
chondrium    and    the    median    line.       Fluctuation    may   be 


6oO        M.I.Vr.l/.    OF   THE   PRACTICE    OF  Ml'.DICIXE. 

appreciated  in  some  cases.  The  colon  lies  in  front  of  the 
cyst,  and  may  be  recognized  by  the  tympanitic  percussion- 
note  obtained  over  it.  The  size  of  the  tumor  varies  from 
time  to  "time  according  to  the  amount  of  urine  passed.  In 
the  rare  cases  of  "  intermittent"  hydronephrosis  the  tumor 
may  entirely  disappear,  with  the  discharge  of  its  contents 
down  the  ureter.  These  cases,  which  are  frequently  con- 
genital, appear  to  be  due  to  a  valve-like  orifice  of  the  ureter, 
which  is  opened  onl\-  when  the  walls  of  the  pelvis  of  the 
kidney  are  dilated  and  put  upon  the  stretch.  In  other 
intermitting  cases  the  ureter  arises  from  the  upper  portion 
of  the  pelvis.  Aspiration  of  the  tumor  differentiates 
hydronephrosis  from  solid  growths,  and  the  character  of 
the  aspirated  fluid  may  confirm  the  diagnosis.  In  other 
cases  intermittent  hydronephrosis  occurs  with  movable 
kidney.  The  growth  of  the  tumor  may  give  rise  to  pres- 
sure-symptoms, nausea  and  vomiting,  and  to  shooting  pains 
extending  down  the  thigh.  Ur.'emic  symptoms  may  occur 
with  bilateral  hydronephrosis  and  in  cases  in  which  nephritis 
occurs  in  the  dilated  kidney.  Suppuration  may  result  in 
the  formation  of  a  pyonephrosis. 

Prognosis. — Death  may  result  from  the  primary  disease, 
from  secondary  hydronephrosis,  or  from  uraemia.  Recovery 
may  follow  if  the  cause  of  the  obstruction  be  removed  ;  it 
may  also  follow  operative  interference. 

Treatment  is  surgical.  When  the  sac  reaches  large  size 
the  fluid  may  be  removed  by  aspiration,  or  the  sac  opened 
and  drained.     The  kidne\'  maybe  extirpated  as  a  last  resort. 

NEPHROLITHIASIS;  RENAL  CALCULI. 

Etiology. — The  solid  constituents  of  the  urine  may  be 
deposited  in  the  kidney  itself  in  several  forms,  to  which  the 
name  "  infarcts"  has  been  incorrectly  applied. 

1.  Uric-acid  infarcts  occur  as  reddish  streaks  at  the  bases 
of  the  pyramids  in  new-born  children  after  the  fourteenth 
day.     They  are  not  found  in  stillborn  children. 

2.  Infarcts  of  sodium  urate,- with  occasionally  ammonium 
urate,  appear  as  whitish  lines  at  the  apices  of  the  pyramids 
in  gouty  kidneys. 


NEPJ/K  O  f.n  Iff.  I  .S7.V.  60 1 

3.  Lime  infarcts,  seen  in  the  kidneys  of  old  people, 
appear  as  white  lines  in  the  pyramids. 

The  term  "  calculi  "  should  more  properly  be  confined  to 
the  concretions  formed  within  the  pelvis  of  the  kidney. 
These  calculi  are  common  to  all  ages  and  are  more  frequent 
in  males  than  in  females.  The  occurrence  of  calculi  of  uric 
acid  or  of  oxalate  of  lime  is  favored  by  gouty  conditions 
and  by  functional  disturbance  of  the  liver.  Phosphatic 
calculi  are  more  commonly  associated  with  inflammations 
of  the  pelvis  of  the  kidney.  Diet  seems  to  exert  no  direct 
influence  upon  the  formation  of  renal  concretions,  but  the  use 
of  hard  drinking-water  containing  lime  seems  to  predispose 
to  their  formation.  The  deposition  of  uric  acid,  according  to 
Roberts,  is  favored  by  the  following  urinary  conditions:  (i) 
High  acidity;  (2)  poverty  of  salines ;  (3)  low  pigmentation; 
(4)  high  percentage  of  uric  acid. 

Patholog-y. — The  important  varieties  of  calculi  are  as 
follows:  (i)  Uric  acid  alone  or  combined  with  concentric 
layers  of  the  urates;  (2)  uric  acid  with  alternating  layers  of 
lime  oxalate  ;  (3)  lime  oxalate  alone  ("  mulberry  calculus"); 
(4)  phosphatic  calculi  of  the  magnesium  salts,  of  the  ammonio- 
magnesium  salts,  or  of  both  ;  (5)  urates  alone,  especially  in 
children  ;  (6)  cystin,  resulting  in  a  soft  concretion  of  bees- 
wax consistency.  A  central  nucleus  is  occasionally  found, 
consisting  of  mucus  or  of  a  small  blood-clot. 

The  ordinary  size  of  the  calculi  varies  from  small  gritty 
particles — "  renal  sand  " — up  to  the  size  of  rice-grains.  In 
the  pelvis  of  the  kidney  there  may  be  found  larger  calculi 
of  an  irregular  branching  shape — the  so-called  "  dendritic 
calculi."  Calculi  forming  perfect  stony  casts  of  the  renal 
pelvis  have  been  described.  Uric-acid  and  oxalate-of-lime 
calculi  are  more  apt  to  be  formed  in  both  kidneys  than  are 
those  of  phosphatic  origin. 

Symptoms  are  produced  by  (i)  the  passage  of  the  cal- 
culus down  the  ureter;  (2)  its  retention  in  the  ureter;  (3) 
its  retention  in  the  pelvis  of  the  kidney. 

I.  Passage  of  tlic  Calculus  through  the  Ureter. — Small 
concretions  may  pass  without  symptoms,  or  may  give  rise 
to  twinges  of  pain  in  the  side,  the  pain  running  down  to  the 


6o2        M.IXi'.lL    OF   THE   PRACTICE    OF  MEDICEXE. 

bhuidcr.  Larsji'cr  calculi,  cntcriiii^  the  ureter,  are  pushed 
downward  in  jerks  In'  the  pressure  of  urine  behind  theni, 
arid  give  rise  to  the  symptoms  of  renal  colic. 

Syniptovis  of  Roial  Colic. — {a)  Pain  is  se\erc,  steady, 
located  in  the  side  or  the  back,  with  cutting  or  tearing  ex- 
acerbations which  radiate  downward  to  the  groin  and  tes- 
ticle. Radiation  upward  does  not  occur.  The  testicle  may 
be  swollen  and  retracted.  The  pain  appears  suddenly,  and 
disappears  with  equal  abruptness  when  the  calculus  drops 
into  the  bladder.  The  pain  is  often  so  intense  that  the  pulse 
becomes  rapid,  feeble,  and  irregular.  Syncope  and  vomiting 
are  commonl}^  observed.  Convulsions  may  occur  in  chil- 
dren. In  some  cases  there  are  chilly  feelings  with  a  mod- 
erate fever  during  the  attack. 

(//>)  Uruiary  Symptoms. — There  is  a  constant  desire  to 
micturate,  and  the  act  may  be  painful  from  an  associated 
spasm  of  the  neck  of  the  bladder.  The  urine,  which  is 
usually  scanty,  may  contain  blood.  It  may  be  suppressed 
either  from  functional  inhibition  or  from  previous  calculous 
disease  with  atrophy  of  the  opposite  kidney.  In  some  ca.ses 
the  urine  is  copious  and  limpid.  After  the  attack  dull, 
aching  pain,  with  some  tenderness  over  the  kidney,  continues 
for  several  days. 

2.  Impaction  of  the  Calculus  witJiiu  the  Ureter. — The  attack 
begins  as  renal  colic  ;  the  cutting  paroxysms  of  pain  grad- 
ually cease,  and  the  dull  ache  alone  remains  for  a  consider- 
able time,  and  finally  disappears. 

(a)  The  calculus  may  finally  be  passed  after  a  period  of 
impaction.  This  fortunate  occurrence  is  more  common  if 
several  calculi  are  impacted  within  the  ureter.  The  passage 
of  the  obstruction  is  accompanied  by  the  symptoms  of  renal 
colic,  usually  with  blood  in  the  urine,  and  may  be  followed 
by  the  passage  of  an  excessive  quantity  of  urine,  especially 
if  the  other  kidney  have  previously  been  disabled  by  calcu- 
lous disease.  In  one  case  of  the  writer's,  in  which  atrophy 
of  the  left  kidney  had  taken  place  by  a  previous  impaction 
of  a  calculus  in  its  ureter,  impaction  in  the  right  ureter  oc- 
curred, with  anuria  of  twelve  days'  duration.  The  final 
passage  of  two  small  calculi  was  followed  by  the  excretion 


NKPJIROJJTJII.IS/S.  603 

ot"  eighteen  pints  of  urine  containing  over  five  ounces  of 
urea,  the  diuresis  not  being  due  to  the  drainage  of  a  hydro- 
nephrosis. 

{6)  If  the  calculus  remain,  completely  obstructing  the 
duct,  urinary  secretion  of  the  kidney  will  cease  as  soon  as 
the  pressure  of  the  pent-uj)  urine  equals  the  blood-pressure 
within  the  renal  artery.  The  kidney  undergoes  atrophy, 
and  is  converted  to  a  little  cyst  in  whose  walls  may  be  seen 
a  thin  shell  of  kidney-tissue.  The  cyst  contains  from  one- 
fourth  to  one-half  an  ounce  of  clear  serum,  or  the  contents 
may  consist  of  inspissated  pus  containing  calculi  and  lime- 
salts.  The  ureter  above  the  impaction  becomes  converted 
to  a  fibrous  cord.  HydronepJirosis  never  occurs  if  the  ob- 
stiniction  be  sudden  and  complete. 

The  symptoms  of  such  an  atrophy  of  the  kidney  depend 
entirely  upon  the  condition  of  its  companion  organ.  If  the 
remaining  kidney  be  in  good  condition,  it  will  be  able  to 
do  the  extra  amount  of  work  required  of  it,  and  no  symp- 
toms will  be  developed.  If  the  other  kidney,  however,  be 
destroyed  in  like  manner  by  previous  calculous  disease,  or, 
as  has  happened,  if  there  be  but  one  kidney,  then  anuria 
develops.  The  characteristic  of  this  obstructive  anuria  is 
that  it  may  exist  for  a  number  of  days  without  marked 
ursemic  symptoms.  Finally,  at  the  end  of  one  or  two  weeks 
uraemic  symptoms  develop,  or  the  patient  may  suddenly 
die. 

In  some  cases  pressure-necrosis  of  the  ureter  at  the  point 
of  impaction  allows  of  perforation  and  of  peritoneal  sepsis. 

If  the  impaction  be  incomplete,  so  that  gradual  back- 
pressure is  exerted  upon  the  pelvis  of  the  kidney,  hydro- 
nephrosis may  be  developed.  This,  however,  is  a  slow  and 
gradual  process. 

3.  If  the  calcidi  remain  in  the  pelvis  of  the  kidney,  they 
tend  to  grow  larger  and  to  assume  the  form  of  the  cavity 
in  which  they  lie.  There  results  from  their  presence  either 
a  pyelitis,  mild,  severe,  or  suppurative,  or  dilatation  of  the 
pelvis  (pyonephrosis),  or  a  suppuration  of  the  kidney  (pyelo- 
nephritis). 

Mild  forms  of  pyelitis  result  in  pain,  of  a  dull,  aching 


604        M.LVi.lL    OF   THE    PRACTK'E    OF  MFDICIXF. 

charr\cter,  usually  increased  b\-  exertion.  The  pain  is 
usually  referred  to  the  kidney  or  to  the  back,  but  it  may  be 
referred  to  the  opposite  kidney — a  point  which  should  be 
remembered  in  operating  upon  such  cases.  From  time  to 
time  there  occur  attacks  of  renal  colic  with  its  characteristic 
pain. 

Toidcnu'ss  over  the  kidne\'  is  usuallx'  detected  by  bi- 
manual palpation. 

The  urine,  which  is  generally  acid  in  reaction,  contains 
mucus,  epithelial  cells  from  the  pelvis  of  the  kidney,  blood, 
pus-cells,  and  crystals  of  uric  acid  or  of  oxalate  of  lime. 
Haematuiia  is  not  profuse,  but  is  apt  to  be  persistent,  and  is 
regularly  increased  by  exercise,  so  that  the  blood  inay  be 
passed  in  considerable  quantities. 

From  time  to  time  there  occur  acute  exacerbations  of  the 
pyelitis.  There  may  be  an  initial  chill  ;  the  temperature 
rises  to  I02°  or  104°  F.  and  is  accompanied  by  severe 
and  distressing  pain  in  the  back.  Profuse  sweating  follows 
the  decline  of  the  fever.  During  the  attack  the  urine 
becomes  smokj'  or  bloody  and  contains  a  large  number  of 
epithelial  cells.  This  "  intermittent  renal  fever,"  which  may 
be  mistaken  for  malarial  fever,  is  identical  with  the  inter- 
mittent hepatic  fever  due  to  gall-stones. 

Severe  cases  of  pyelitis  may  merge  into  those  of  suppu- 
rative pyelo-nephritis  and  pyonephrosis.  The  symptoms  of 
pyelitis  become  aggravated,  pus  appears  in  the  urine,  and 
chills,  fever,  and  other  septic  symptoms  develop.  If  the 
opposing  kidney  be  previously  destroyed  by  calculous  dis- 
ease, pyelo-nephritis  may  lead  to  fatal  uraemia.  Other  cases 
die  in  a  septicctmic  condition. 

Treatment  should  be  directed  toward  the  following  con- 
ditions : 

I.  The  habitual  passage  of  uric- acid  or  oxalatc-of-lime 
crystals.  Usually  there  is  found  some  digestive  error. 
The  bowels  should  be  kept  regular;  the  functions  of  the 
liver  should  be  stimulated  by  cholagogues  and  occasional 
doses  of  calomel.  The  use  of  dilute  hydrochloric  acid 
(TTLxv  in  a  glass  of  water  to  be  drunk  during  meals)  is  often 
of  the  greatest  service,  especially  in  cases  of  oxaluria.     A 


NE/'//K(>L/77//.IS/S.  605 

reduction  should  be  ordered  in  fats,  sugars,  alcohol,  and 
meat,  but  fruits,  vegetables,  and  milk  may  be  given  freely. 
The  most  important  part  of  the  treatment  is  to  enforce 
regular  and  systematic  exercise  ;  unless  this  can  be  done, 
the  effects  of  dietetic  and  medicinal  treatment  may  not  be 
apparent. 

2.  Attacks  of  renal  colic.  The  indication  is  to  relieve  the 
pain  and  spasm.  The  patient  should  at  once  be  immersed 
in  a  hot  bath,  or  hot  applications  may  be  applied  to  the 
abdomen.  Morphine  is  to  be  given  in  |-grain  doses  hypo- 
dermically,  and  is  preferably  combined  with  atropine.  The 
same  caution  attends  its  use  as  in  biliary  colic.  The  pain 
having  a  tendency  to  cease  suddenly,  the  tolerance  for  the 
drug  will  also  cease,  and  toxic  symptoms  may  appear  if  the 
drug  be  given  in  too  liberal  doses.  While  the  patient  is 
passing  under  the  effects  of  the  morphine  whiffs  of  chloro- 
form may  be  necessary  to  mitigate  the  agony.  After  the 
attack  is  over  the  urine  for  some  days  should  be  filtered 
through  gauze  or  through  a  fine  sieve  to  find  the  stone,  and 
by  analysis  its  chemical  composition  may  be  determined. 

3.  If  the  stone  be  impacted  in  the  uretei^,  treatment  is 
given  with  a  view  to  relax  the  spasm  of  the  wall  of  the 
ureter,  and  to  increase  the  quantity  of  urine,  so  as  to  push 
the  stone  along. 

Spasm  is  relaxed  by  continuous  hot  applications  and  hot 
baths,  during  which  the  abdomen  may  be  kneaded  gently, 
and  by  small  doses  of  morphine  and  atropine.  Increased 
secretion  of  urine  is  accomplished  by  raising  the  blood- 
tension  by  appropriate  heart-stimulants,  the  preferable  drug 
for  this  purpose  being  digitalis. 

If  medicinal  treatment  be  of  no  avail,  and  if  anuria  per- 
sist, showing  permanent  disability  of  the  other  kidney,  the 
stone   may  be  removed  surgically. 

If  the  stone  remain  in  the  pelvis  of  the  kidney,  various 
forms  of  solvent  treatment  have  been  recommended. 
Citrate  of  potash  is  to  be  given  in  doses  sufficient  to  keep 
the  urine  neutral  in  reaction.  The  treatment  must  be  dis- 
continued as  long  as  the  urine  is  alkaline  or  ammoniacal. 
According  to  Roberts,  three  conditions   are  necessar\"  for 


6o5        MAXr.-lL    OF   THE    PA'.IC/7C/-:    OF  MEDJCfXF. 

success  in  this  treatment :  the  calculus  must  be  of  uric 
acid  ;  it  must  be  of  small  size  ;  antl  the  urine  must  not  be 
alkaline  or  ammoniacal,  as  otherwise  sodium  biurate  or 
phosphate  is  precipitated  upon  the  calculus,  rendering 
further  solution  impossible. 

Instead  of  the  citrate  of  potassium,  alkaline  mineral 
waters  may  be  given  for  the  same  purpose,  but,  according 
to  Haig,  the  lithium  waters  are  useless.  For  the  oxalate- 
of-lime  calculi  there  is  no  solvent  treatment.  If  the  pain 
be  so  severe  as  to  interfere  with  the  patient's  earning  a 
living,  or  if  suppurative  pyelo-nephritis  or  pyonephrosis 
develop,  the  ki(.lne\-  ma\-  be  cut  down  upon  and  the  calculi 
removed  or  the  kidney  extirpated.  Care,  however,  should 
be  taken  that  the  other  remaining  kidney  is  competent,  and 
not  atrophied  from  previous  disease  or  congenitall)'  absent. 

PERINEPHRITIC  ABSCESS. 

Etiolog-y. — Suppuration  of  the  pennephritic  tissues  may 
result  from  traumatism  or  from  extension  of  suppuration 
from  the  kidney,  intestine  (especially  the  vermiform  appen- 
dix), liver,  or  spinal  column.  Burrowmg  downward  of  a 
perforating  empyema  has  occurred. 

Symptoms. — As  the  disease  is,  properly  speaking,  a  sur- 
gical one,  but  a  brief  description  of  the  symptoms  will  be 
given.  Pain  and  tenderness  are  present  in  the  lumbar 
region.  The  pain  is  somewhat  relieved  by  keeping  the 
body  immobile  and  by  flexing  the  thigh.  In  rare  cases  the 
pain  may  be  altogether  referred  to  the  hip-joint  or  to  the 
knee.  In  the  lumbar  region  there  may  be  detected  a 
tender,  indurated  mass  which  in  the  latter  stages  may  yield 
a  sense  of  fluctuation.  The  abscess  may  appear  externally, 
or  internal  rupture  in  any  direction  may  occur. 

The  constitutional  symptoms  are  those  of  an  internal 
abscess — chills,  fever,  and  the  gradual  development  of 
sepsis. 

Treatment  consists  in  opening  and  draining  the  abscess. 


VL  CONSTITUTIONAL  DISEASES. 


ACUTE  ARTICULAR  RHEUMATISM;    RHEUMATIC 

FEVER. 

Etiology. — Rheumatism  may  occur  at  any  time  of  the 
year,  but  it  is  more  common  ni  the  spring  months.  Hered- 
ity is  traced  in  25  per  cent,  of  the  cases.  One  attack  pre- 
disposes to  successive  attacks,  and  relapses  are  common. 
No  age  is  exempt.  It  is  very  common  in  children,  and  it 
may  even  be  a  disease  of  intra-uterine  life.  It  occurs  espe- 
cially in  those  leading  a  life  of  exposure,  and  the  exciting 
cause  may  be  wet  and  cold  or  over-strain  of  a  muscle  or  a 
joint.     The  disease  is  rare  in  the  tropics. 

Rheumatism  at  certain  times  assumes  epidemic  propor- 
tions, and  when  this  is  the  case  the  clinical  features  are  apt 
to  vary. 

The  following  theories  of  rheumatism  have  been  advanced; 
no  one  of  them  has  been  satisfactorily  proven : 

1.  The  nervous  theory,  that  rheumatism  depends  upon  dis- 
turbances of  the  nerve-centres  presiding  over  the  nutrition 
of  joints. 

2.  The  lactic-acid  theory,  that  rheumatism  is  due  to  the 
presence  of  lactic  acid  in  the  blood,  due  to  some  perverted 
tissue-change  of  muscle. 

3.  The  7iric-acid  theory  of  Haig,  that  uric  acid  formed  in 
the  blood  may  be  deposited  in  the  joints  by  diminished 
alkalinity  of  the  blood.  It  has  been  supposed  that  lactic 
and  uric  acid  in  combination  might  produce  the  lesions. 

4.  The  tlieory  of  inicrobic  infection  is  based  upon  the  gen- 
eralization of  the  lesions,  the  involvement  of  the  fibro-serous 
membranes  so  commonly  involved  in  other  known  bacterial 
diseases,  the  constitutional  predisposition  seen  in  many 
patients,  and  the  occurrence  of  occasional  epidemics  of  the 

(i07 


6o8        J/.l.VC.IL    OF  THE    PRACTICE    OF  MEDICIXE. 

disease.  No  germ  lias  yet  been  isolated,  althoui^jh  ex- 
periments seem  to  confirni  the  theor\-  of  bacterial  in- 
fection. 

Symptoms.  —  i.  Goicral. — The  onset  nia>'  begin  acutely 
with  a  chill  and  f'c\'er,  or  subacute!)'  b\'  shooting  pains  in 
the  joints,  malaise,  and  moderate  fever.  In  rarer  cases  the 
joint-symptoms  are  the  first  symptoms  observed. 

The  fever  is  rarel\-  intense,  usually  under  103°  F.,  and 
runs  no  t\pical  course.  Formerl)'  its  duration  was  from 
two  to  four  weeks,  but  owing  to  improved  methods  of  treat- 
ment it  now  rarely  lasts  more  than  from  two  to  fi\e  days. 
In  children  the  fever  is  but  moderate,  and  it  may  even  be 
absent.  It  is  important  to  watch  the  temperature  through- 
out the  disease.  A  rise  in  temperature  usually  means  a 
fresh  invasion  of  joints,  or  some  complication,  such  as  endo- 
carditis or  pericarditis,  while  a  fall  generally  implies  a  sub- 
sidence of  the  disease  and  modifies  the  therapy.  The  occur- 
rence of  hyperpyrexia  will  be  noted  later. 

The  pulse  is  full  and  dicrotic 

The  urine  is  diminished,  is  of  increased  acidity  and  high 
specific  gravity,  and  contains  urates  and  an  increased  quan- 
tity of  uric  acid.      Febrile  albuminuria  may  be  observed. 

Cerebral  symptoms  are  not  seen  except  in  cerebral  rheu- 
matism with  hyperpyrexia  or  in  over-dosing  of  salicylic 
acid. 

The  blood  in  rheumatism  becomes  rapidly  anaemic.  In 
the  majority  of  cases  there  occur  drenching  sweats  of  a 
peculiarly  sour  odor,  and  the  skin  may  show  sudaminal 
vesicles. 

2.  Inflammation  of  Fibro-scrous  Membranes. — The  joints 
are  almost  regularly  involved,  giving  a  distinct  clinical  type 
to  the  disease.  In  children,  however,  joint-symptoms  are 
regularly  less  marked  than  in  adults,  and  may  be  absent 
altogether  (the  "  abarticular  "  form).  The  lesion  is  a  simple 
serous  synovitis.  The  synovial  membrane  is  h)'per;i:;mic ; 
its  cavity  is  filled  with  serum  and  flocculi  of  fibrin.  There 
is  no  pus-formation.  There  are  often  similar  lesions  in  the 
sheaths  of  adjacent  tendons.  There  are  pain,  increased  by 
motion,  and  tenderness  of  the  affected  joints.     The  extent 


ACUTE   ARTICULAR   RJIKUMAT/SM.  609 

and  character  of  the  swelling  depend  upon  the  amount  of 
synovial  effusion  and  the  involvement  of  the  adjacent  ten- 
don-sheaths. The  skin  over  the  joint  is  usually  hot,  red- 
dened, and  not  infrequently  is  oedematous.  These  symp- 
toms are  less  marked  in  children,  who  may  only  show  some 
rigidity  to  passive  motion  of  the  joint,  and  a  continued  posi- 
tion of  flexion  which  is  especially  marked  in  the  knees, 
and  appears  to  be  due  to  inflammation  of  the  sheaths  of  the 
hamstring  tendons,  the  joints  themselves  escaping. 

Characteristic  of  rheumatic  synovitis  are  the  great  rapidity 
of  its  development  and  subsidence,  the  involvement  of  many 
joints  by  jumps  (fresh  articulations  being  involved  while 
those  first  attacked  are  recovering),  and  the  rarity  of  its 
attacking  one  joint  alone.  Monarticular  rheumatism  is  so 
uncommon  that  a  diagnosis  of  rheumatism  should  always 
be  made  with  extreme  caution.  The  larger  joints  are 
especially  liable  to  be  attacked,  but  the  small  joints  of  the 
hands  and  the  feet  may  be  involved.  Any  joint  may  be 
attacked,  but  the  temporo-maxillary  articulation  is  so  rarely 
involved  as  to  throw  doubt  on  the  diagnosis,  should  this 
joint  be  affected.  Symmetry  of  involvement  is  rare,  the 
disease  differing  in  this  respect  from  acute  rheumatic  arthri- 
tis. Pain  and  swelling  often  persist  after  the  acute  process 
has  subsided,  and  there  may  be  some  stiffness  from  adhe- 
sions within  the  joint-cavity.  An  acute  attack  may  be  fol- 
lowed by  any  of  the  forms  of  subacute  or  chronic  rheuma- 
tism. Recurrences  of  acute  rheumatism  are  exceedingly 
common,  especially  in  the  rheumatism  of  young  people. 

Subacute  rheumatism  represents  a  milder  form  of  rheu- 
matism. The  constitutional  and  local  symptoms  are  less 
intense,  but  the  duration  of  the  disease  is  longer  than  in  the 
acute  form,  and  the  condition  tends  to  become  chronic. 

Complications  of  Rheumatism. — i.  Cardiac  Affections. 
— The  endocardium  and  the  pericardium  may  be  involved 
in  mild  as  well  as  in  severe  attacks  of  rheumatism,  and  may 
even  be  inflamed  without  any  involvement  of  the  joints,  as 
in  the  abarticular  rheumatism  of  children.  The  liability  to 
heart-complications  is  most  common  in  children ;  this  liabil- 
ity diminishes  with  increasing  age.     The  heart-membranes 


6lO        M.lXr.lL    OF   niE   PKACTICE    of  MEDICIXE. 

arc  not  usuall\-  involved  after  the  first  week,  if  absolute  rest 
and  a  restricted  diet  be  enforced. 

{a)  Pericarditis,  which  complicates  from  lO  to  20  per  cent, 
of  the  cases,  may  occur  alone  or  with  endocarditis.  The 
inflammation  ma\-  be  fibrinous,  fibrino-serous.  or  purulent, 
and  it  is  often  associated  with  hyperpyrexia  and  delirium. 
The  rheumatic  pericarditis  of  children  often  runs  an  obscure 
course.  The  child  grows  pale  and  emaciated,  and  dies  of 
exhaustion  or  of  heart-failure  without  the  development  of 
either  dropsy  or  dyspnoea. 

{Jii)  Endocarditis  is  more  commonh'  a  rheumatic  lesion 
than  pericarditis,  and  it  appears  in  a  large  percentage  of 
both  mild  and  severe  cases.  Endocarditis  may  even  be  the 
solitary  manifestation  of  the  abarticular  rheumatism  of  chil- 
dren. The  mitral  valve  is  the  one  most  frequently  affected. 
Valvular  disease  may  not  lead  to  serious  consequences,  or 
slow  changes  may  ensue,  resulting  in  vahailar  thickening 
and  retraction.  In  a  few  cases  there  occurs  an  added  infec- 
tion of  micrococci,  resulting  in  malignant  endocarditis. 

(r)  Myocarditis  is  almost  regularly  secondary  to  endo- 
cardial or  pericardial  changes. 

2.  Pulinonary  Affections. — {d)  Pleurisy  usually  results  by 
extension  from  a  pericarditis,  and  is  therefore  left-sided  and 
more  intense  in  the  portion  of  the  pleura  in  most  direct  con- 
tact with  the  pericardium.  The  pleuris}-  is  usually  fibrinous, 
rarely  fibrino-serous. 

{b)  RJieuviatic  pnenmonia  rarely  occurs  except  in  connec- 
tion with  pericarditis,  and  is  left-sided.  The  pneumonia 
ma)'  present  certain  peculiarities  :  (i)  Absence  of  the  criti- 
cal fall  of  temperature ;  (2)  frequent  absence  of  cough  ;  (3) 
rarity  of  rusty  sputum  ;  (4)  great  rapidit}-  with  \\hich  the 
physical  signs  clear  up. 

3.  Hyperpyrexia  is  probably  due  to  the  action  of  the 
rheumatic  poison  upon  the  heart-centres,  and  is  of  compara- 
tively rare  occurrence.  It  appears  more  commonly  in  hot 
weather ;  it  is  more  frequent  in  men  than  in  women,  and 
especially  in  those  with  weak  nervous  systems.  It  is  un- 
known in  childhood,  the  greatest  liability  being  between  the 
twentieth  and  thirtieth  years.     It  is  almost  unknown  after 


ACUTE   ARTICULAR    R IJI:UMA'TISM.  6l  I 

the  third  attack  of  rheumatism.  In  one-half  the  cases  peri- 
carditis is  present.  In  an  equal  number  of  cases  the  joint- 
symptoms  subside  as  the  hyperpyrexia  develops.  The 
hyperpj'rexia  may  complicate  mild  or  severe  cases.  The 
onset  of  high  fever  may  be  sudden,  or  it  may  be  preceded 
by  headache,  delirium  at  night  (not  due  to  salicylic  acid), 
restlessness,  hyperesthesia  of  the  skin,  or  excessive  mictu- 
rition. The  fever  may  rise  gradually  or  suddenly  to  106'^, 
108°,  or  110°  F.,  or  there  may  be  merely  a  high  range  of 
temperature  for  a  number  of  days,  without  any  acute  exacer- 
bation. Prostration,  delirium,  and  coma  usually  appear,  and 
may  terminate  fatally. 

4.  Ccj'ebral  complications  complicate  the  hyperpyrexia, 
and  occur  only  in  about  2  per  cent,  of  the  cases.  Cerebral 
symptoms  may  suddenly  develop,  or  they  may  be  preceded 
by  the  same  prodromal  symptoms  as  in  hyperpyrexia. 
These  preliminary  symptoms,  if  proven  not  to  be  due 
to  salicylic-acid  poisoning,  should  excite  grave  appre- 
hensions. 

According  to  Duckworth,  cerebral  rheumatism  assumes 
one  of  three  clinical  types  : 

[a)  There  is  delirium,  mild  and  wandering  or  so  violent  as 
to  call  for  restraint,  followed  by  semi-coma,  coma,  and 
death. 

{b)  The  patient  passes  suddenly  into  coma,  which  termi- 
nates fatally,  at  times  within  a  few  hours. 

{c)  There  are  well-marked  spasmodic  symptoms,  followed 
by  fatal  coma. 

In  the  great  majority  of  the  cases  of  cerebral  rheumatism 
hyperpyrexia  is  present,  and  if  the  temperature  be  over  106° 
F.,  a  fatal  issue  is  almost  certain  unless  prompt  treatment 
be  adopted. 

The  pathology  of  cerebral  rheumatism  is  obscure.  The 
brain  may  be  normal,  anaemic,  or  congested.  In  rare 
instances  there  are  found  evidences  of  an  acute  meningitis. 

5.  The  relation  of  chorea  to  rheumatism  will  be  con- 
sidered under  the  former  disease. 

6.  Cutaneous  Complications. — There  may  be  a  fine  miliary 
rash,  or  an  eruption  resembling  that  of  scarlet  fever.     Pur- 


012        MAXLAL    OF   llIE    PRACTICE    OF  MEDICINE. 

pura  is  not  uiicoiiinion,  aiul  the  x^arious  toinis  of  urticaria 
and  erythema  may  occur. 

7.  R/icii)Na(ic  Nodiili's. — Subcutaneous  nodules,  varying 
from  a  barel}'  appreciable  size  up  to  that  of  a  bean,  may 
appear,  attached  to  the  tendon-shoaths,  to  the  deep  fascia 
coverini:^  the  bony  prominences,  and  to  the  cranium.  Those 
attached  to  the  tendon-sheaths  are  frcel\'  mo\able.  During 
the  early  stages  of  their  development  the\'  may  be  a  little 
tender,  but  when  of  longer  duration  they  are  absolutely 
painless.  They  are  most  numerous  on  the  fingers,  the 
hands,  the  wrists,  and  about  the  elbow-joints,  but  they  may 
appear  upon  the  patellar,  the  spines  of  the  vertebrae,  the  skull, 
and  the  clavicles.  They  may  appear  during  an  attack  of 
rheumatism  or  after  its  decline,  and  they  are  more  common 
in  the  abarticular  rheumatism  of  children.  They  ma\'  last 
for  weeks  or  months,  and  they  are  regarded  as  a  positive 
indication  of  rheumatism.  The}' consist  of  connective  tissue 
undei'going  rapid  proliferation. 

8.  Pharyngitis  and  Tonsillitis. — Pharyngitis  is  not  uncom- 
mon in  rheumatic  subjects,  and  is  characterized  by  the 
amount  of  pain  being  out  of  proportion  to  the  apparent 
degree  of  inflanmiation.  Rheumatic  pharyngitis  may  be 
practically  considered  as  an  erythematous  affection  of  the 
fauces,  of  a  nature  similar  to  cutaneous  erythema. 

Tonsillitis  occurs  in  repeated  attacks  in  rheumatic  sub- 
jects, and  max-  complicate  an  acute  rheumatic  attack. 

Treatment. — Except  in  very  subacute  cases,  the  patient 
should  be  put  to  bed,  no  matter  how  mild  the  case,  and  not 
be  allowed  to  get  up  until  the  acute  symptoms  liave  entirely 
subsided.  The  diet  should  be  of  milk  and  farinaceous  food, 
nitrogenous  food  being  absolutely  contraindicated.  Lemon- 
ade or  the  alkaline  mineral  waters  may  be  given  freely. 
The  patient  should  not  be  exposed  to  draughts,  and  should 
sleep  between  light  blankets. 

Local  treatment  to  the  affected  joints  is  often  grateful. 
The  joints  may  be  encased  in  cotton  and  rendered  immobile 
by  padded  splints.  Hot  applications  are  usually  well  borne, 
hot  solutions  of  i  per  cent,  of  acetate  of  alumina  or  of  lead 
and   opium  being  highly  efficacious.     Counter-irritation  by 


ACUTE   AKT/Cl'I.AR    A'/fEUA/A'/VSAl.  613 

the  thermo-cautcry  or  by  small  blisters  about  the  joint 
sometimes  relieves  the  pain.  The  joints  may  be  bathed 
with  chloroform  liniment,  or  ichthyol  ointment  (3j  :.?j)  may 
be  applied.  Ice-bags  are  at  times  more  grateful  than  hot 
applications,  and  are  much  used  on  the  Continent  of 
Europe. 

Constitutional  Treatment. — Salicylic  acid  (gr.  v-x),  sodium 
salicylate  (gr.  x-xx),  salol  (gr.  v-x),  salophen  (gr.  v-x),  and 
oil  of  wintergreen  (TTl  x-xx  in  capsule  or  in  milk)  may  be 
given  in  the  indicated  doses  every  two  hours  until  slight 
deafness  and  buzzing  noises  in  the  ears  are  experienced, 
after  which  the  dosage  is  to  be  reduced  gradually.  This 
salicylic-acid  treatment  seems  to  have  no  effect  in  redu- 
cing the  duration  of  the  disease  nor  in  preventing  cardiac 
complications,  but  it  exerts  a  specific  effect  upon  the  fever 
and  the  pain,  the  temperature  falling  to  normal  and  the 
articular  pains  disappearing  within  from  two  to  five  days. 
It  is  said  that  relapses  are  more  common  under  this  than 
under  the  alkaline  treatment,  but  the  so-called  "  relapses  " 
are  probably  recrudescences  of  the  disease,  as  the  symp- 
toms of  rheumatism  tend  to  recur  should  the  treatment  be 
discontinued  too  soon  or  should  too  small  doses  of  the 
salicylic  acid  be  given.  Toxic  syrnptoms — gastric  disturb- 
ances, delirium,  cardiac  weakness,  albuminuria,  and  a  tend- 
ency toward  hemorrhages — should  not  appear  if  the  patient 
be  conscientiously  watched. 

The  alkaline  treatment  seems  to  lessen  the  liability  to 
cardiac  complications.  The  treatment  consists  in  giving 
alkalies  in  dose  sufficient  to  keep  the  urine  alkaline.  For 
this  purpose  sodium  bicarbonate  in  sj-ij  doses  should  be 
given  every  three  hours,  in  water  rendered  effervescent  by 
the  addition  of  the  juice  of  half  a  lemon.  The  urine 
becomes  alkaline  usually  within  twenty-four  hours,  after 
which  time  only  enough  alkali  is  given  to  keep  the  alkalin- 
ity of  the  urine  constant.  The  addition  of  quinine  sulphate 
(gr.  iij-v)  to  each  dose  of  the  alkali  seems  to  increase  its 
therapeutic  value.  The  alkaline  treatment  may  be  given 
alone,  but  it  is  preferably  combined  with  the  salic}'l  com- 
pounds.      Trimethylamine    and    benzoic    acid    or    sodium 


6 14        M.IXC.IL    OF  THE   FRACTICE    OF  MFDIC/XE. 

benzoate  have  been  reconinicndcd  for  rheumatism,  but  their 
action  is  inferior  to  that  of  the  saHcylates. 

For  the  reUef  of  pain  opium  may  be  necessary.  Phen- 
acetine  is  of  service,  and  antipyrine,  in  lO-grain  doses  every 
three  or  four  hours,  is  useful  in  controUing  the  pains  of 
afebrile  rheumatism. 

Hx'perpyrcxia  is  to  be  treated  by  the  energetic  use  of  the 
wet  pack  or  the  cold  bath,  and  no  time  should  be  lost  in 
reducing  the  temperature. 

The  treatment  of  the  cardiac  and  pulmonary  complica- 
tions is  considered  under  their  respective  sections. 

During  convalescence  iron  is  indicated  to  relieve  anaemia, 
and  the  alkaline  treatment  should  be  continued  for  some 
weeks  after  the  cessation  of  acute  symptoms.  Over-use 
of  the  joints  should  be  avoided.  During  convalescence 
nitrogenous  food  should  be  interdicted. 

PSEUDO-RHEUMATISM  (SECONDARY 
RHEUMATISM). 
Under  this  heading  are  included  a  number  of  forms  of 
articular  disease  secondar}'  to  a  variety  of  infectious 
diseases,  usually  of  septic  origin.  Among  the  most  com- 
mon of  these  diseases  are  the  articular  affections  complicat- 
ing mumps,  dysentery,  scarlet  fever,  typhoid  fever,  puer- 
peral fever,  pyaemia,  purpura  rheumatica,  .syphilis,  and 
gonorrhoea.  The  characteristics  of  these  pseudo-rheu- 
matic affections  will  be  considered  in  connection  with 
the  diseases  from  which  they  originate. 

CHRONIC   ARTICULAR  RHEUMATISM. 

Etiology. — The  chronic  form  may  follow  acute  rheumatism, 
or  the  disease  may  be  chronic  from  the  start.  Persons  past  the 
middle  age  of  life,  and  whose  occupation  exposes  them  to 
wet  and  cold,  are  more  liable  to  be  attacked.  The  disease 
is  greatly  influenced  by  weather,  and  exacerbations  may 
recur  evcr\-  autumn  and  last  throughout  the  winter. 

Pathology. — The  synovial  membrane  is  congested,  and, 
together  with  the  capsule  of  the  joint,  is  thickened.  The 
thickening  may  also  extend  to  tlie  fibrous  structures  about 


CHRONIC  ARriCULAK    N  JJRl -MA-nSAJ.  615 

the  joint.  Slight  erosions  of  the  articular  cartilages  may 
occur,  in  protracted  cases.  There  may  be  deformities  from 
the  contraction  of  fibrous  bands  formed  about  the  diseased 
joints  [rhciunatisvie  fibrcnx),  and  in  advanced  cases  ankylo- 
sis of  the  joint  may  occur.  There  may  be  atrophy  of  the 
muscles  about  the  diseased  joint,  from  disuse,  from  centric 
nervous  causes,  or  from  neuritis.  Muscular  contraction  is 
not  uncommon.  Osteophytic  deposits  do  not  occur  as  in 
arthritis  deformans.  There  are  no  cardiac  complications 
as  in  the  acute  form. 

Symptoms. — Pain  and  stiffness  characterize  the  affected 
joints,  and  acute  exacerbations  may  occur,  especially  after 
over-exertion  of  the  joints  or  during  cold,  damp  weather. 
The  affected  joints  are  tender  to  the  touch  and  are  usually 
somewhat  swollen.  Synovial  crackling  may  be  appreciated 
on  movement,  and  may  readily  be  distinguished  from  the 
bony  grating  common  to  anthritis  deformans.  As  a  rule, 
many  joints  are  involved,  especially  those  exposed  to  fatigue 
in  the  patient's  ordinary  occupation.  In  working-women 
the  small  joints  of  the  hand  are  usually  favorite  seats  of  the 
disease.  Ulnar  deflection  of  the  fingers  is  common,  but  the 
deflection  is  not  permanent  except  in  the  fibrous  or  ankylotic 
form.  In  rare  cases  the  disease  assumes  a  monarticular 
form,  involving  the  hip,  the  knee,  or  the  shoulder.  The 
course  of  the  disease  is  afebrile,  and  the  general  health  does 
not  directly  suffer  from  the  disease. 

The  prognosis  is  good  for  life,  but  is  bad  for  recovery 
from  the  rheumatism. 

Treatment. — The  clothing  should  be  warm,  and  exposure 
to  cold,  damp  weather  should  be  avoided.  Salicylic  acid  is 
useless.  A  number  of  drugs  have  been  recommended  for 
this  disease — potassium  iodide,  colchicum,  arsenic,  alkalies, 
guaiac,  preferably  combined  with  potassium  citrate  and 
tincture  of  cinchona — but  the  efficacy  of  internal  treatment 
can  seldom  be  demonstrated.  Good  results  have  been 
claimed  for  ichthyol  (gr.  v  three  times  a  day  in  pill  form). 
The  best  results  are  obtained  by  improving  the  patient's 
nutrition  (tonics,  nutritious  food,  and  cod-liver  oil),  by  ap- 
plying counter-irritation  to  the  joints  (thermo-cautery,  iodine, 


6l6        MAXC'AL    OF   rilE   rKACTICE    OF  MFDIC/XE. 

blisters),  and  by  sending  the  patient  for  tlie  winter  months  to 
a  warm,  equable  chniate.  Hot  alkaHne  waters  are  particu- 
larly useful,  and  sulphur-waters  have  also  been  recom- 
mended. The  thermal  springs  may  be  advised,  together 
with  a  change  of  climate.  Alkaline  baths  have  been  recom- 
mended, but  they  are  not  to  be  advised  in  the  case  of  those 
over  sixty  years  of  age  with  atheroma  and  myocardial 
degeneration. 

MUSCULAR    RHEUMATISM. 

Etiology. — The  exact  nature  of  this  affection  is  unknown. 
The  condition,  which  commonly  occurs  after  exposure  to 
cold  and  after  over-use  of  the  muscles,  is  more  frequent  in 
those  of  a  rheumatic  or  gouty  habit.  One  attack  renders 
the  patient  susceptible  to  recurrences. 

The  patholog-y  is  unknown.  The  disease  may  be  a  mild 
form  of  inflammation  of  the  muscles  (mj^ositis),  or  the  affec- 
tion may  be  entirely  neuralgic. 

Symptoms. — There  is  pain,  dull  and  aching  or  sharp 
and  cramp-like,  in  the  affected  muscles,  and  the  pain  is 
regularly  increased  by  motion.  The  pain  is  generally  re- 
lieved by  pressure,  but  there  may  be  decided  muscular  ten- 
derness. The  affected  muscles  may  be  contracted,  so  that 
the  attitude  of  the  patient  frequently  gives  evidence  as  to 
the  seat  of  the  disease.  Special  names  are  given  to  muscu- 
lar rheumatism  according  to  the  location  of  the  difficulty. 
Lumbago  affects  the  muscles  of  the  small  of  the  back  and 
their  tendinous  attachments.  Torticollis,  or  "  wry-neck," 
usually  affects  the  sterno-cleido-mastoid  muscle  of  one  side, 
but  both  muscles  may  be  affected,  and  the  muscles  of  the 
back  of  the  neck  are  often  involved.  Pleurodynia  involves 
the  intercostal  muscles  of  one  side,  and  occasionally  the 
pectorals,  the    latissimus   dorsi,   and   the  serratus   magnus. 

The  duration  of  muscular  rheumatism  is  usually  brief,  but 
the  disease  may  at  times  run  a  subacute  or  a  chronic  course. 

Treatment. — Rest  for  the  affected  muscles  is  of  the  first 
importance.  As  the  pain  begins  to  wear  away,  the  sub- 
sidence of  the  disease  may  be  hastened  by  massage.  In 
some  cases  massage  will  cut  short  a  pronounced  attack,  and 


GOUT.  617 

the  effects  of  the  manipulations  may  be  increased  by  the  use 
of  stimulating  hniments.  Strapping  of  the  side  gives  relief 
in  pleurodynia.  Phenacetine  combined  with  salol  or  with 
salicylic  acid  frequently  cuts  short  an  attack,  and  should 
always  be  used  as  routine  treatment.  Steaming  by  covering 
the  affected  muscles  with  damp  cloths  and  passing  a  hot 
iron  over  them  is  a  domestic  remedy  of  established  value. 

A  hot  bath  may  be  recommended.  Rapid  cure  frequently 
follows  "  firing  "  with  the  thermo-cautery.  The  use  of  the 
constant  current  is  also  beneficial.  Osier  recommends  acu- 
puncture for  lumbago,  sterilized  bonnet-needles  three  or 
four  inches  long  being  thrust  into  the  affected  muscles  and 
retained  from  five  to  ten  minutes.  In  many  cases  instant 
relief  follows  this  procedure. 

GOUT  (PODAGRA). 

Etiolog-y. — Gout  may  be  either  inherited  or  acquired. 
Inherited  gout  is  very  common  among  the  better  classes  in 
England,  Germany,  and  France,  but  is  rare  among  the  Irish. 
An  inherited  tendency  is  seen  in  75  per  cent,  of  the  cases. 
Gout  may  be  acquired  by  habits  ofease,  indolence,  and  dis- 
sipation, by  over-eating  and  over-indulgence  in-alGohol,  by 
deficient  bodily  exercise,  and  by  any  cause  exhausting  the 
great  nerve-centres.  It  may  be  acquired  through  poisoning 
by  lead,  as  Garrod  found  that  30  per  cent,  of  his  hospital 
cases  of  gout  could  be  traced  to  this  origin.  Gout  cannot 
always  be  traced  to  high  living,  as  cases  of  "poor  man's 
gout "  are  not  uncommon,  the  disease  being  induced  by 
improper  hygiene,  poor  food,  and  indulgence  in  malt  liquors. 
In  America  the  acute  forms  of  gout  are  uncommon,  but  the 
irregular  manifestations  of  the  'disease  are  not  infrequent. 
The  disease  occurs  more  often  in  men  than  in  women.  The 
inherited  form  usually  appears  earlier  in  life  than  the  ac- 
quired form,  which  does  not  generally  appear  until  the  fifth 
decade. 

Three  theories  of  gout  have  been  advanced  : 
I.   TJie    Uric-acid   Theory  (Garrod). — From  renal  insuffi- 
ciency the  excretion   of  uric   acid  is   diminished,  and  the 
symptoms  of  gout  arise  from  its  retention  in  the  blood  and 


6lS        MAXL'.IL    OF   THE   PKACTICE    OF  MFDICIXE. 

tissues  and  from  the  efforts  of  nature  to  expel  it.  The  de- 
posit of  crystaUized  urates  in  the  joints  gives  rise  to  the 
classical  inflammatory  symptoms.  Haig  has  thus  modified 
the  uric-acid  theor\- :  The  deposit  of  urates,  according  to 
his  modification,  is  not  due  to  their  excessive  production 
nor  to  deficient  elimination,  but  is  produced  by  all  conditions 
associated  with  diminished  alkalescence  of  the  blood. 

2.  The  "  Xcn'ous"  or  "  Ahnui-Junnoral"  Theory  (Duck- 
worth).— Two  conditions  must  be  complied  with:  (i)  The 
patient  must  possess  the  arthritic  or  diathetic  habit  from 
which  gout  and  rheumatism  arise,  and  (2)  there  must  exist 
some  functional  disturbance  of  the  nerve-centres  to  account 
for  the  sudden  explosion  of  the  .symptoms.  This  "  gouty 
neurosis "  may  be  inherited,  acquired,  intensified,  or  re- 
pressed. The  causative  effect  of  depressing  physical  and 
mental  circumstances  in  inducing  gout  seems  to  lend  cor- 
roboration to  the  nervous  theory. 

3.  Ebstein  believes  that  a  local  necrosis  occurs  in  certain 
tissues  from  local  nutritive  disturbance,  and  that  in  the 
necrotic  areas  the  urates  are  deposited  secondarily.  The 
nutritive-tissue  disturbance  may  be  inherited  or  acquired. 

Pathology. — The  blood  contains  an  excess  of  uric  acid. 
This  condition,  however,  also  occurs  in  leukaemia,  and  is  not 
therefore  distinctive.  The  joints  usually  affected  are  the 
great  toe,  the  small  joints  of  the  hands  and  the  feet,  and, 
least  frequentl}',  larger  joints  without  an\'  marked  order  of 
preference.  During  an  acute  attack  the  sx-novial  membrane 
is  congested,  the  ligaments  are  swollen,  and  there  is  an  in- 
crease in  the  synovial  fluid.  The  articular  cartilages  appear 
as  if  whitewashed,  from  an  interstitial  deposit  of  the  sodium 
urate,  with  occasionally  the  addition  of  the  calcium  salt.  In 
advanced  cases  the  cartilage  becomes  roughened  and  eroded 
and  infiltrated  with  urates,  while  deposits  of  urates  are  seen 
in  the  ligaments  and  in  the  neighboring  fibrous  structures. 
The  synovial  fluid  is  often  transformed  to  a  pasty  mass  of 
urates. 

Secondary  inflammatorx'  lesions  consist  of  bony  marginal 
outgrowths,  and  in  ulceration  b\-  which  the  gouty  masses 
may  be  discharged  through  the  skin.     The  joint  becomes 


GOUT.  619 

distorted  and  immobile,  and  complete  ankylosis  may  result. 
Gouty  concretions  or  "  tophi  "  are  frequently  seen  under 
the  skin,  in  the  eyelids  and  the  ears,  and  in  other  parts  of 
the  body. 

Associated  lesions  are  of  great  importance. 

1.  The  kidneys  may  show  deposits  of  sodium  urate  as 
whitish  lines  in  the  apices  of  the  pyramids.  Chronic  diffuse 
nephritis  is  so  commonly  present  that  the  name  "  gout\' 
kidney "  has  frequently  been  applied  to  this  form  of 
nephritis. 

2.  The  arteries  are  frequently  the  seat  of  chronic  endar- 
teritis. Atheroma  and  calcareous  deposits  upon  the  aortic 
valves  are  not  infrequent. 

3.  Hypertrophy  and  dilatation  of  the  heart  result  from 
the  nephritis,  from  the  endarteritis,  and  from  the  atheroma 
of  the  aortic  valves. 

4.  Emphysema  with  chronic  bronchitis  is  almost  con- 
stantly present  in  the  chronic  forms  of  gout. 

5.  Chronic  gastro-enteritis  or  chronic  colitis  is  frequent 
in  long-standing  cases. 

Symptoms. — Gout  may  be  described  as  occurring  in 
acute,  chronic,  and  irregular  forms. 

Acute  Gout. — There  may  be  premonitions  of  an  attack. 
These  premonitions  consist  of  twinges  of  pain,  cramps  in 
the  calves,  irritability  of  temper,  and  dyspepsia.  A  pre- 
liminary asthmatic  attack  may  also  occur.  The  urine  is 
usually  over-acid  and  concentrated,  and  deposits  urates. 
There  may  be  a  temporary  albuminuria  or  glycosuria.  The 
quantity  of  uric  acid  eliminated  before  and  during  the  early 
period  of  the  attack  is  regularly  diminished.  The  attack 
itself  generally  appears  suddenly,  usually  during  the  early 
morning  hours,  with  a  characteristic  pain  in  the  metatarso- 
phalangeal joint  of  the  great  toe,  usually  of  the  left  side. 
The  pain  is  grinding,  throbbing,  and  excruciating,  and  is 
entirely  disproportionate  to  the  evident  inflammation.  The 
joint  becomes  swollen,  dusky-red,  shiny,  and  tender.  The 
veins  of  the  foot  become  turgid.  As  the  attack  wears  off 
the  foot  usually  becomes  oedematous,  and  desquamation  of 
the  skin  over  the  joint  is  observed.     An  initial  chill  is  not 


620        M.l.yC'.lf.    OF   THE   PRACTICE    OF  MEDICLXE. 

iinconinioii.  I^Y'\-er  aniountiiiL^  to  102°  or  103°  V .  is  alnu>st 
reguIarK'  obscrvcti. 

Other  joints  may  become  involved,  especialK'  the  joint 
of  the  great  toe  of  the  other  foot,  but  this  extension  of 
the  disease  is  not  common.  A  practical  rule  is  that  all 
cases  of  suddenly  induced  severe  monarthritis  should  be 
suspected  to  be  of  gouty  origin.  In  rarer  cases  the  knee- 
joint  is  the  one  primarily  involved. 

The  attack  terminates  favorably  within  a  week  or  ten 
days,  unless  the  response  to  treatment  be  exceedingly 
prompt,  and  the  patient  is  left  with  a  weakened,  tender 
joint  for  some  little  time.  Usually,  after  an  acute  attack 
the  general  health  is  markedly  improved. 

The  terms  "  suppressed  "  and  "  metastatic  "  gout  are  ap- 
plied to  sudden  and  severe  internal  s)-mptoms  coincident 
with  the  rapid  disappearance  of  the  outward  inflammatory 
siens.      The  following  varieties  mav  be  described  : 

1.  Cardiac  gout  consists  of  sudden  pain  in  the  heart,  .syn- 
cope, and  heart  failure  which  may  be  fatal.  If  the  patient 
recover,  dyspnoea  and  palpitation  appear. 

2.  Cerebral  Gout.  —  There  may  be  mental  confusion, 
delirium,  or  mania.  Apoplectiform  seizures  with  coma 
ma\'  occur.  Temporary  insanity  has  been  observed.  In 
some  of  these  cases,  however,  the  cerebral  symptoms  have 
been  ura^mic. 

3.  Gastro-intestinal  Gout. — Pain  in  the  stomach,  nausea, 
and  vomiting  are  not  infrequent.  Profuse  diarrhoea  may 
occur,  with  death  in  collapse. 

4.  ]\sual  gout  is  characterized  by  t'requent  painful  mic- 
turition and  haematuria. 

5.  Testicular  gout  is  accompanied  by  painful  swelling  of 
the  testis. 

Chronic  Gout. — As  the  acute  attacks  become  more  fre- 
quent the  local  processes  fail  to  leave  the  joints.  The  joints 
show  various  deformities,  depending  on  the  bony  out- 
growths from  the  periphery  of  the  articular  cartilages,  from 
visible  deposit  of  urates,  and  from  enlargement  of  and  gouty 
deposits  in  the  superjacent  bursae.  Synovial  distention  is 
less    common    in     gout    than    in    rheumatism.       Crackling 


GOll'J'.  621 

sounds  are  heard  when  the  joints  are  moved.  Pain  and 
weakness  are  experienced  in  the  affected  joints,  which  first 
are  those  of  the  feet,  then  those  of  the  hands.  Tophi 
appear  about  the  joints  and  in  the  ears,  and  may  be  dis- 
charged through  the  skin.  The  skin  becomes  soft  and 
satin-hke.  Symptoms  of  the  associated  lesions  appear — 
high-tension  pulse  from  the  arterial  changes,  hypertrophy 
or  dilatation  of  the  left  ventricle,  abundant  urine  of  low 
specific  gravity,  and  uremic  symptoms  from  the  nephritis. 
Emphysema,  bronchitis,  and  chronic  intestinal  catarrh  com- 
plicate the  course  of  the  disease  in  almost  all  cases. 

Irregular  or  abarticular  gout  is  extremely  common, 
occurring  as  an  inherited  and  as  an  acquired  form.  Various 
symptoms  appear  in  different  members  of  gouty  families 
and  among  those  whose  habits  are  such  as  to  predispose  to 
gout.  The  symptoms  are  so  varied  and  assorted  that  only 
a  brief  mention  can  be  made  of  the  most  important : 

1.  Qitaneo?is  Symptoms. — Eczema  is  frequent,  especially 
the  dry,  scaly  variety.  Pruritus  ani  and  hot  itching  feet 
at  night  are  commonly  the  source  of  much  distress. 

2.  G astro-intestinal  Symptoms. — Dyspepsia  is  the  rule. 
Flatulence,  over-acidity,  constipation,  coated  tongue,  "  bil- 
iousness," and  the  symptoms  of  functional  disturbance  of 
the  liver  are  usually  present. 

3.  Urinary  Symptoms. — The  urine  is  usually  over-acid 
and  deposits  urates,  uric  acid,  and  lime  oxalate.  Temporary 
glycosuria  and  albuminuria  are  not  uncommon,  especially 
in  patients  of  advanced  years.  The  symptoms  of  chronic 
diffuse  nephritis  without  exudation  may  appear.  Renal 
calculi  are  not  uncommon,  and  are  usually  of  the  uric-acid 
variety.  Urethritis  may  develop  without  gonorrhcEal  in- 
fection. 

4.  Cerebral  symptoms  are  not  uncommonly  distressing. 
They  comprise  mental  hebetude,  loss  of  memory,  irritability 
of  temper,  headaches  of  such  severity  as  to  suggest  organic 
disease,  vertigo,  and  sleeplessness.  The  eyesight  is  com- 
monly blurred,  and   the    eyeballs  may  be  hot  and   itching. 

5.  Cardio-vascular  Symptoms.  —  Vaso-motor  symptoms 
are   common,   and   consist  of  "  hot  and  cold  flushes  "  and 


622        J/.I.Vr.lL    OF   THE   PKACJICE    OF  MEDICI XE. 

sudden  s\vcatini:;;s.  The  pulse  is  one  of  hiL;h  tension. 
Palpitation  is  a  common  symptom.  The  arterial  changes 
may  lead  to  the  s\'mptoms  of  hypertrophied  or  dilated 
heart,  atheroma  of  the  aorta  or  of  the  coronary  vessels, 
aneurysm,  or  sudden  death. 

6.  Piihnoiiary  syitiptonis  include  chronic  bronchitis,  em- 
physema, and  asthmatic  attacks. 

7.  Locomotor  Orgtvis. — Shooting  pains,  stiffness,  and  sub- 
tendinal  bursitis  are  common.  Cramps  in  the  calves  of  the 
legs,  burning  feelings  in  the  feet  at  night,  and  tenderness  in 
the  heels  on  standing  may  appear.  Gouty  neuralgia  is  not 
infrequent,  and  involves  the  sciatic  nerve  with  greatest 
frequency. 

8.  Eye-affcctioiis. — A  number  of  conditions  may  occur, 
among  which  iritis  and  glaucoma  are  the  most  important. 
Conjunctivitis  is  not  uncommon,  and  may  be  due  to  gouty 
tophi   in   the   upper  lid. 

Prognosis. — Gout  is  seldom  the  actual  cause  of  death 
except  in  the  rare  visceral  forms ;  but  the  disease  is  ren- 
dered serious  by  reason  of  the  nephritis  and  the  arterial 
sclerosis  which  so  frequentl)'  complicate  the  disease,  and  it 
is  upon  these  latter  conditions  that  the  prognosis  depends. 

Treatment. — During  an  acute  attack  of  gout  the  foot 
should  be  elevated  and  wrapped  in  cotton.  Hot  applica- 
tions are  often  of  service,  hot  whiskey  and  water  being  a 
favorite  application.  Menthol  may  be  used  in  alcoholic 
solution.    The  following  prescription  is  used  by  Duckworth : 

I^.     Atropinae,  gr.  iij ; 

Morphinse  hydrochloratis,  gr.  xv  ; 

Acidi  oleici,  .  .5j. — M. 

Sig.   Paint  over  painful  joint  with  a  camel's-hair  brush. 

Colchicum  has  a  specific  effect  on  acute  gout,  and  the  wine 
or  the  tincture  should  be  given  in  doses  of  from  15  to  20 
minims  every  four  hours,  preferably  combined  with  potas- 
sium citrate.  A  preliminary  mercurial  purge  is  usually 
given  with  advantage.  The  administration  of  colchicum 
should  be  watched  carefully,  and  gastric  distress  and  pur- 


GOUT.  623 

gation  should  be  avoided.  In  cases  where  colchicum  fails 
or  is  not  well  borne,  potassium  citrate  or  acetate  in  20-  to  30- 
grain  doses  may  be  given  every  two  liours,  combined  with 
diluent  drinks.  The  preparations  of  salicylic  acid  are  often 
employed,  but  their  action  is  inferior  to  that  of  colchicum. 
Phenacetine  or  chloral  hydrate  may  be  given  for  the  relief 
of  the  pain,  but  morphine  is  to  be  used  with  extreme  cau- 
tion. The  diet  during  the  acute  attack  should  consist 
largely  of  milk  and  light  farinaceous  foods,  and  alcohol 
should  be  withdrawn  unless  especially  indicated  as  a  stimu- 
lant. 

TJic  treatment  of  clu'onic  and  irregular  gout  is  largely  by 
diet  and  hygiene.  Starchy  and  saccharine  food  should  be 
avoided  ;  beer  and  wines  should  be  prohibited  absolutely. 
Lean  meats,  eggs,  fish,  green  vegetables,  and  milk  should 
constitute  the  principal  portions  of  the  diet.  Sweet  fruits, 
berries,  melons,  and  bananas  are  to  be  omitted  from  the 
dietary,  but  oranges  and  lemons  may  be  allowed.  The  food 
should  be  simple,  wholesome,  and  indulged  in  with  modera- 
tion. If  stimulants  are  needed,  whiskey  with  water  is  the 
least  injurious  form.  The  patient  should  drink  freely  of 
pure  water  or  of  any  of  the  alkaline  mineral  waters. 

Hygienic  treatment  consists  of  daily  baths  with  friction 
of  the  skin  and  regular  systematic  exercise.  Exercise  is 
one  of  the  most  satisfactory  means  of  treating  irregular 
gout,  but  it  should  not  be  carried  to  the  point  of  fatigue. 

The  medicinal  treatment  is  symptomatic.  Lithia-water 
is  of  great  service.  7\n  artificial  lithia-water  can  be  made 
by  dissolving  a  3-grain  tablet  of  effervescing  lithium  citrate 
in  each  glass  of  table-water  that  is  taken  throughout  the 
day.  Constipation  is  relieved  by  occasional  mercurial  pur- 
gatives and  by  the  steady  use  of  podophyllin  and  rhubarb. 
Small  doses  of  colchicum  (TTlv-x  of  the  wine)  with  10 
grains  of  potassium  iodide  are  of  service  during  the  more 
active  manifestations  of  the  disease.  Quinine,  guaiac,  and 
the  benzoates  are  also  recommended.  Iron  and  arsenic 
should  be  given  for  anaemic  conditions.  In  obstinate  cases 
much  good  is  derived  from  a  course  of  treatment  at  medici- 
nal springs,  such  as  the  White  Sulphur  Springs  or  those  at 


624        M.lXr.tL    OF   THE   PRACTJCE    OF  MFD/CLVE. 

Saratoc^a.  Carlsbad,  Kissingen.  or  Homburg.  The  effects 
of  the  treatment  are  largel\'  due  to  tlie  iini)roved  dietetic 
and  h\'gienic  conditions  that  attend  a  course  of  treatment  at 
these  places. 

ARTHRITIS    DEFORMANS. 

Etiolog-y  and  Synonyms. — This  disease  may  be  primary 
in  its  origin,  or  it  ma)'  follow  rheumatism,  gout,  or  gonor- 
rhoeal  arthritis;  85  per  cent,  of  the  cases  occur  in  women, 
especially  in  those  at  the  time  of  the  menopause.  The 
influence  of  heredit)'  is  often  marked,  especially  among 
the  female  members  of  a  gout\-  family.  Rarely  the  disease 
may  occur  in  children.  The  true  nature  of  the  disease  is 
obscure,  but  it  seems  probable  that  there  is  a  nervous 
origin.  This  neuropathic  theory  is  based  upon  the  disease 
frequentl}'  following  depressing  nervous  or  mental  shocks, 
upon  the  extreme  symmetry  of  the  lesions,  and  upon  the 
atrophic  changes  occurring  in  the  nails,  the  skin,  rmd  the 
muscles.  In  many  respects  the  lesions  resemble  the  arthro- 
pathies of  locomotor  ataxia.  Syfio?i}'iiis :  Rheumatoid 
arthritis ;    Rheumatic    gout. 

Pathology. — The  joint-cartilage  becomes  fibrillated,  soft, 
and  velvety,  and  is  worn  away  in  the  centre,  exposing 
thickened,  polished,  eburnated  bone-surfaces.  At  the  periph- 
ery of  the  cartilages  a  lipping  or  a  heaping  up  is  observed, 
from  which  bony  outgrowths  form — the  osteophytes.  Im- 
mobility and  deformity  result  from  the  interlocking  and 
mutual  obstruction  of  these  osteophytes,  but  bony  ankylosis 
does  not  occur  except  in  the  spinal  column.  The  synovial 
membrane  and  the  fibrous  capsule  become  greatly  thickened. 
Synovial  distention  is  rarely  extreme.  Ligaments  which 
pass  in  or  through  the  diseased  joints  may  be  absorbed.  In 
some  cases  the  articular  ends  of  the  bones  may  be  increased 
in  length  and  thickness,  but  in  old  people  the  bones  may 
become  atrophied  and  spongy.  Atrophic  changes  occur 
about  the  affected  joints ;  the  muscles  undergo  atrophy,  the 
nails  become  brittle,  the  skin  assumes  a  glossy  appearance, 
and  neuritis  can  frequently  be  demonstrated. 


.  /  A'  7 11 R  /  7  7S   DK  FOKMA  NS.  62  5 

Symptoms. — Three  clinical  types  of  the  disease  may  be 
described : 

1.  Heberdcn's  Nodes. — The  lesions  involve  the  phalan- 
geal joints,  and  little  nodules  (Heberden's  nodes)  develop 
on  the  distal  phalanges.  These  nodes  are  composed  of 
osteophytic  outgrowths,  and  may  show  small  cystic  swell- 
ings at  their  summits,  due  to  hernia  of  the  joint-capsule. 
The  joints  may  be  swollen  and  painful  after  indiscretions  in 
diet  or  when  they  are  accidentally  struck,  but  usually  the 
chief  symptom  is  limitation  of  motion.  The  phalangeal 
joints  are  somewhat  enlarged,  and  may  yield  a  bony 
grating  on  passive  motion.  The  affection  is  incurable,  but 
does  not  tend  to  advance. 

2.  TJie  Polyarticular  Form. — This  form  may  develop 
aciLtcly  and  may  be  mistaken  for  acute  articular  rheumatism. 
It  may  be  distinguished  from  the  latter  disease,  however, 
by  the  symmetrical  involvement  of  the  small  peripheral 
joints,  by  bony  outgrowths  from  the  articular  ends  of  the 
bones,  and  by  the  uselessness  of  salicylic  acid.  The  acute 
form  of  onset  is  most  frequent  in  young  women  who  have 
recently  borne  children. 

In  other  cases  the  onset  is  subacute. 

The  chronic  form  is  the  most  frequent.  Premonitory 
symptoms  are  at  times  observed — numbness  and  tingling 
of  the  skin  over  joints,  rapid  and  high-tension  pulse,  and  a 
persistent  pain  in  the  ball  of  the  thumb.  The  small  periph- 
eral joints  are  usually  the  first  involved,  and  the  lesions 
tend  to  advance  steadily  toward  the  trunk.  The  temporo- 
maxillary  articulation  is  often  involved.  A  characteristic 
feature  is  the  extreme  symmetry  seen  in  the  distribution  of 
the  lesion,  for  not  only  are  corresponding  joints  simultane- 
ously involved,  but  the  lesions  progress  in  them  with  identi- 
cal rapidity.  The  joint-symptoms  consist  of  pain,  swelling, 
and  limitation  of  motion.  Pain  is  variable  :  it  may  be  parox- 
ysmal or  of  a  steady,  gnawing  character,  increased  by  mo- 
tion and  by  warmth  in  bed,  or  there  may  be  neuralgic  pain 
or  the  pain  of  muscular  cramp.  The  enlargement  of  the 
joints  is  due  to  thickening  of  the  capsule,  to  bony  out- 
growths, and  in   some  cases  to  synovial  distention.     Bony 

40 


626        M.tXr.l/.    OF   THE   PKACriCK    OF  MEDICIXE. 

crepitus  can  usually  be  excited  b)'  passi\-e  motion.      In  time 
the  joints  become  completel\'  locked  anil  immobile.      De- 


FiG.  52. — Deformity  of  arthritis  deformans. 


formitics  arc  caused  not  onl\'  b\'  distortion  by  the  osteo- 
phytes, but    also    by  muscular   atrojjhy  and    spasm.     The 


DIABF/FKS  MFJJJ'J'US.  62/ 

tendon-reflexes  are  usually  increased,  and  ankle-clonus  may- 
be present. 

3.  TJic  Monarticular  Form. — This  form  is  most  frequent 
in  old  people,  and  in  men.  The  hip,  the  knee,  the  shoulder, 
and  the  spinal  column  are  the  parts  usually  affected.  In 
many  cases  there  is  a  history  of  previous  joint-injury.  In 
old  people  especially  a  slight  injury  is  often  sufficient  to  set 
up  what  may  be  regarded  as  a  senile  change.  The  lesions 
are  essentially  those  previously  described,  but  great  atrophy 
of  the  ends  of  the  affected  bones  is  characteristic  of  the 
disease  in  old  people. 

When  affecting  the  hip-joint  of  the  aged,  the  disease  has 
been  termed  "  morbus  coxae  senilis."  Pain,  limitation  of 
motion,  bony  grating,  and  shortening  are  observed.  The 
gluteal  region  is  flattened  from  muscular  atrophy. 

When  affecting  the  spinal  column,  the  disease  has  been 
termed  "  spondylitis  deformans."  Bony  ankylosis  is  com- 
mon, so  that  immobility  of  the  vertebral  column  iii  the.  in- 
volved section  results. 

The  prognosis  is  bad  for  recovery,  although  life  is  usually 
not  shortened  by  the  disease.  Death  occurs  from  intercur- 
rent disease,  from  chronic  nephritis,  or  from  tuberculosis. 
The  disease  may  be  arrested  at  any  stage,  or  it  may  progress 
so  that  the  patient  is  practically  crippled. 

Treatment. — Arthritis  deformans  is  practically  an  incur- 
able disease.  Much  good  can  be  done,  however,  by  build- 
ing up  the  general  health  and  by  the  steady  administra- 
tion of  arsenic.  A  temporary  improvement  may  follow 
prolonged  treatment  by  hot  mineral  baths  or  by  drinking 
the  waters  of  thermal  springs.  Massage  may  be  of  service 
in  preventing  the  muscular  atrophy  of  disease. 

DIABETES  MELLITUS. 

The  term  "  diabetes  "  should  be  limited  to  those  cases  in 
which  sugar  accumulates  in  the  blood  and  is  excreted  in  the 
urine,  accompanied  by  constitutional  symptoms.  The  term 
"  glycosuria  "  should  be  applied  only  to  those  cases  in  which 
sugar  appears  in  the  urine  in  small  amounts  without  consti- 


628         M.LXCAL    OF   THE   PRACTICE    OF  MEDICIXE. 

tutional  symptoms,  or  appears  onl\'  as  a  temporar\'  condi- 
tion. 

Etiology. — The  disease  may  be  induced  by  long-continued 
indulgence  in  saccharine  food,  especially  if  the  patient  be  of 
sedentar\-  habits.  In  many  cases  tiie  influence  of  heredity 
is  marked.  The  disease  ma)-  follow  lesions  or  injuries  of 
the  brain  or  of  the  spinal  cord,  and  it  has  been  produced 
artificially  b\'  puncture  of  the  floor  of  the  fourth  ventriclejust 
behind  the  pneumogastric  nucleus  ( Bernard's  diabetic  cen- 
tre). Lesions  causing  atropli)'  in  extensive  disease  of  the 
pancreas  have  been  followed  so  frequently  by  diabetes  that 
a  special  form  of  "  pancreatic  diabetes  "  has  been  described. 
Psychical  disturbances,  such  as  worry,  care,  and  depressing 
emotions,  have  been  followed  by  the  disease,  and  in  some 
cases  diabetes  has  succeeded  certain  infectious  diseases,  such 
as  syphilis,  gout,  and  malaria.  Disturbances  of  the  liver 
have  also  been  adduced  as  causative  factors.  The  disease 
is  wiot  as  common  in  America  as  on  the  Continent  of 
Europe.  Men  are  more  frequently  attacked  than  women, 
and  the  greatest  liability  occurs  in  adult  life.  Children 
under  ten  years  of  age  are  usually  exempt.  Hebrews  seem 
to  be  predisposed  to  diabetes,  and  the  disease  is  more  com- 
mon among  the  higher  classes. 

To  explain  the  disease  a  number  of  theories  have  been 
advanced.  Nervous  lesions,  diseases  of  the  pancreas  and  the 
liver,  insufficient  alkalescence  of  the  blood-plasma,  and  de- 
ficient oxidation-processes  have  each  been  the  subject  of 
separate  hypotheses,  but  no  one  theory  has  been  established 
definitely. 

Pathology. — A  number  of  different  lesions  have  been 
found,  no  one  of  which  seems  to  be  either  constant  or 
essential.     The\^  may  be  thus  classified  : 

1.  The  blood  contains  an  excess  of  urea,  fat,  and  sugar. 
The  fat-particles  may  be  visible  in  coagulated  blood  ;  the 
sugar  may  be  raised  from  the  normal  0.15  per  cent,  to 
0.40  per  cent. ;  glycogen  may  be  found  within  the  leuco- 
cytes. 

2.  Ncn'ous  System. — There  may  be  tumors  or  cysts  in- 
volvincr  the  "  diabetic  centre  "  in  the  medulla  or  involvin^r 


DIABF.rES  AiEij.rrus.  629 

the  cerebrum.  Anaemia,  oedema,  or  atrophy  of  the  cortical 
convolutions  may  be  found,  or  congestion  and  thickening 
of  the  meninges.  Perivascular  changes  in  the  brain  and 
the  cord  may  occur.  There  may  be  found  a  tumor  press- 
ing on  the  vagus.  Peripheral  neuritis  is  not  uncommon. 
The  sympathetic  ganglia  may  be  enlarged. 

3.  Cardio-vasctilar  System. — The  heart  may  be  fatty  or 
enlarged.  Hypertrophy  is  not  uncommon,  and  dilatation 
may  be  the  cause  of  death.  Endarteritis  is  frequently 
observed.  Endocarditis  may  result  from  the  irritation  of 
the  endocardium  by  the  sugary  blood. 

4.  The  liver  may  be  fatty  or  may  be  the  seat  of  cirrhotic 
change.  A  peculiar  form  of  pigmentary  degeneration  is 
described.     For  this  form  of  "  diabete  bronze  "  see  page  523. 

5.  The  pane j'e as  may  be  firm  and  atrophied,  may  be  the 
seat  of  pigmentary  cirrhosis,  or  may  be  the  seat  of  cancer, 
of  cysts,  or  of  fat-necrosis. 

6.  The  kidneys  are  usually  fatty.  Glycogen  is  often 
found  in  the  epithelium  of  Henle's  tubes.  Chronic  ne- 
phritis  is  common. 

7.  The  lungs  frequently  show  the  lesions  of  broncho- 
pneumonia or  of  lobar  pneumonia.  Gangrene  may  occur. 
The  lungs  of  diabetics  are  frequently  the  seat  of  tubercular 
inflammation. 

8.  The  nincous  inenibranes  are  usually  the  seat  of  chronic 
catarrhal  inflammation. 

The  symptoms  of  diabetes  mellitus  begin  insidiously. 
The  first  symptom  noticed  may  be  an  unnatural  thirst,  the 
passage  of  too  much  urine,  or  a  loss  of  flesh.  In  some 
cases  the  disease  is  first  appreciated  by  an  accidental  exam- 
ination of  the  urine.  In  rare  instances  it  sets  in  rapidly. 
When  the  disease  is  developed  the  symptoms  are  changes 
in  the  urine,  thirst,  hunger,  progressive  emaciation,  and  the 
symptoms  due  to  the  complications. 

I.  The  uri)ie  is  usually  pale,  of  a  sweetish  odor  and  taste, 
and  is  of  a  specific  gravity  ranging  between  1025  and  1045, 
although  a  lower  specific  gravity  may  occur  if  the  quantity 
of  urine  be  enormously  increased.  The  acidity  is  high. 
The  urine   irritates   the  genitals,  causing   intense  pruritus,- 


630        .y.lXl-.-lL    OF   THE   PRACTICE    OF  MEDICIXE. 

whicli  may  be  the  first  syniptoni  for  wliicli  the  patient 
apphes  for  rehef  Urea  and  phosphates  are  passed  in 
excess,  and  acetone  may  be  detected.  A  special  form  of 
diabetes  has  been  described,  "  phosphatic  diabetes  "  (Ralfe), 
in  which  phosphates  are  greatly  increased,  although  the 
sugar  may  not  be  present  constantly.  Transient  albuminuria 
is  observed  in  about  one-third  of  the  cases.  The  quantity 
of  urine  passed  varies  between  two  and  fifteen  quarts,  from 
four  to  six  quarts  being  the  quantity  in  average  cases.  In 
rare  instances  polj'uria  is  not  observed.  The  percentage 
of  sugar  varies  up  to  from  i  to  2  per  cent,  in  mild  cases, 
and  to  from  5  to  10  per  cent,  in  the  severer  forms.  The 
total  daily  excretion  of  sugar  varies  up  to  from  ten  to 
twenty  ounces,  but  it  may  exceed  one  to  two  pounds  in  the 
twenty-four  hours.  Sugar  may  temporarily  disappear  dur- 
ing the  course  of  severe  intercurrent  diseases.  The  best 
methods  of  detecting  and  estimating  the  sugar  are  by 
Fehling's  test  and  the  fermentation-test.  For  details  of 
these  tests  the  reader  is  referred  to  works  on  urinary 
analysis. 

2.  Excessive  hunger  and  tJiirst  are  observed  in  almost  all 
cases.  Thirst  may  be  a  distressing  symptom.  As  a  rule, 
the  food  is  well  digested,  but  from  the  excessive  amount 
taken  dilatation  of  the  stomach   may  occur. 

3.  Emaciation  is  most  marked  in  young  subjects,  in 
whom  the  disease  seems  to  run  a  more  malignant  course. 
The  tongue  is  usually  dry  and  glazed,  the  gums  swell  and 
bleed,  and  aphthous  stomatitis  may  occur.  Saliva  is  scanty. 
The  skin  is  dry  and  scaly,  but  in  some  cases  drenching 
sweats  may  occur,  the  perspiration  being  charged  with 
sugar  and  lactic  acid.  Intense  general  pruritus  is  often 
distressing,  and  this  symptom  is  always  highly  suggestive 
of  either  diabetes  or  internal  cancer.  Constipation  is  the 
rule. 

4.  Complicating  symptoms  are  exceedingly  numerous. 

{a)  Cutaneous  Symptoms. — Boils  and  carbuncles  are  com- 
mon, and  suppurative  processes  are  liable  to  follow  opera- 
tions. Purpura  is  frequent.  Gangrene  may  occur,  and  is 
more   frequently   observed    in   the   feet.      The   nails    may 


yV./A'A7'A'.V   MKL/.fllJS.  63 1 

atrophy,  and  the  hair  may  fall  out.  The  occurrence  of 
pruritus  has  been  mentioned. 

(^)  Genito-iin)iary  Syviptoms. — Irritation  and  pruritus  of 
the  external  genitals  are  common.  In  men  balanitis  occurs. 
Impotence  may  be  an  early  symptom.  Cystitis  may  occur. 
The  symptoms  of  a  chronic  nephritis  may  be  added  to 
those  of  the  diabetes. 

(c)  Puhnonary  complications  are  not  uncommon.  Lobar 
pneumonia,  broncho-pneumonia,  and  gangrene  of  the  lung 
may  occur.  Tubercular  disease  is  common,  and  runs  a 
rapid  but  somewhat  insidious  course. 

id)  Cardio-vascular  Symptoms.  —  Symptoms  of  arterial 
sclerosis  are  commonly  present,  and  the  heart  is  hypertro- 
phied.  Dilatation  may  ensue,  and  may  lead  to  a  fatal  issue. 
Sudden  death  from  fatty  heart  is  not  uncommon. 

{e)  Nervous  symptoms  are  important. 

Diabetic  coma  occurs  especially  in  young  subjects,  and  is 
usually  associated  with  rapid  emaciation.  Preceding  the 
onset  the  urine  may  be  diminished  in  quantity,  although  the 
excretion  of  sugar  remains  unchanged.  Three  clinical 
forms  of  diabetic  coma  are  encountered. 

(i)  After  severe  bodily  or  mental  exertion  the  patient 
develops  prostration  with  rapid  and  feeble  heart-action, 
passes  into  coma,  and  dies  within  a  few  hours. 

(2)  The  patient  suffers  for  a  few  days  from  weakness, 
constipation,  dyspnoea,  and  abdominal  pain.  Then  develop 
headache,  restlessness,  delirium,  great  dyspnoea  amounting 
to  "  air-hunger,"  cyanosis,  and  rapid  and  feeble  heart-action. 
The  breath  has  a  sweetish  odor  resembling  that  of  rotten 
apples.     Coma  terminates  the   disease  within  a  few  days. 

(3)  Neither  dyspnoea  nor  prostration  appears,  but  the 
patient  complains  of  sudden  severe  headache,  feels  as  if  in- 
toxicated, becomes  rapidly  stupid  and  comatose,  and  dies  in 
a  few  hours. 

The  exact  nature  of  diabetic  coma  is  unknown.  It  has 
been  ascribed  to  toxaemia  from  acetone  or  from  oxybutyria 
acid.  In  other  cases  it  has  seemed  to  be  due  to  uraemia  or 
to  fat-embolism  of  the  branches  of  the  pulmonary  artery 
within  the  luns". 


632        M.IXL'.IL    OF   TJJK   PRACTICE    OF  MEDICIXE. 

Peripheral  Neuritis. — Mild  forms  of  neuritis  give  rise  to 
neuralgic  pains,  numbness  and  tingling,  and  muscular 
weakness.  Severe  forms  cause  lightning  pains  in  the  legs, 
loss  of  tendon-reflex,  paresis  of  the  extensors  of  the  feet, 
and  a  characteristic  gait.  To  this  grouping  of  symptoms 
the  term  "  diabetic  tabes"  has  been  applied.  In  other  cases 
paraplegia  has  been  observed,  and  both  hands  and  feet  may 
be  affected. 

(/")  Mental  symptoDis  consist  of  melancholia,  and  in  some 
cases  general  paresis  has  resulted. 

(yg^  Rye. — Cataract  is  common,  especially  in  young  sub- 
jects, and  develops  with  great  rapidity.  Retinitis,  hemor- 
rhages in  the  retina,  optic  atrophy,  and  sudden  blindness 
have  occurred.  There  may  be  parah^sis  of  the  muscles  of 
accommodation. 

Prognosis. — Complete  recovery  cannot  be  expected,  al- 
though a  large  number  of  patients  enjoy  good  health  for  a 
number  of  years,  and  the  disease  in  them  may  be  controlled 
b\'  diet.  A  considerable  number  of  the  cases  die  of  heart 
failure,  diabetic  coma,  pulmonary  affections,  or  nephritis. 
A  smaller  number  die  exhausted  and  emaciated  from  the 
diabetes  alone.  As  a  rule,  the  older  the  patient  the  slower 
the  course  of  the  disease.  In  cases  under  forty  years  of 
age  the  prognosis  is  exceedingly  grave.  The  cause  under- 
lying the  diabetes  must  always  be  taken  into  account  in 
rendering  the  prognosis. 

The  treatment  is  by  diet  and  by  drugs. 

Diet. — Sugars  and  starches  should  be  excluded,  as  far  as 
possible,  from  the  food.  Saccharin  or  glycerin  may  be  sub- 
stituted for  sugar.  All  fruits  and  vegetables  that  abound  in 
starch  should  be  prohibited  ;  among  these  are  potatoes,  rice 
and  cereals,  flour-  and  starch-compounds,  beans,  peas,  tur- 
nips, grapes,  plums,  apricots,  pears,  apples,  melons,  figs, 
berries,  beets,  onions,  and  asparagus.  Beer,  cider  and 
champagne,  and  sweet  wines  should  also  be  prohibited. 
Among  other  food-sub.stances  to  be  avoided  are  liver,  crabs, 
lobsters  and  oy.sters,  thick  gravies,  and  soups.  Theoreti- 
cally, bread  should  be  prohibited,  and  gluten  bread  be  given 


GLYCOSURIA.  633 

instead,  but,  as  this  is  not  readily  taken  by  the  patient,  its 
use  cannot  in  all   cases  be  insisted   upon. 

Among  the  articles  that  may  be  taken  are  butcher's 
meat,  game,  poultry,  fish,  clams,  eggs,  bacon,  butter,  cream, 
cheese,  nuts,  spinach,  tomatoes,  cabbage,  cauliflower,  lettuce, 
cucumbers  and  pickles,  gluten,  bran,  and  almond-meal 
bread,  clear  soups,  lemons,  tea,  coffee,  and  cocoa. 

As  a  rule,  the  diet  should  be  modified  gradually,  one  pro- 
hibited article  after  another  being  cut  off  Care  should  be 
taken  that  the  patient's  strength  is  not  too  far  reduced  by 
the  restricted  diet. 

Drug  Treatment. — The  following  forms  of  treatment  have 
been  recommended,  and  are  given  in  the  order  of  preference : 
Clemens'  solution  (a  i  percent,  solution  of  arsenic  bromide) 
may  be  given  in  3-  to  5 -drops  doses  after  meals.  Opium  is 
a  valuable  drug,  and  in  diabetes  there  exists  a  tolerance  for 
its  use.  Codeia  may  be  given  in  3^-grain  doses  three  times 
daily,  and  may  be  increased  to  from  6  to  8  grains  in  the 
day ;  or  morphine  may  be  given  (gr.  \  doses  t.  i.  d.),  and 
increased  until  the  daily  dose  is  about  5  grains.  The  i-grain 
opium  pill  may  also  be  used.  Bicarbonate  and  salicylate  of 
sodium  may  be  given  in  i-  to  2-dram  doses  in  the  day. 
Sulphide  of  calcium  (gr.  /^-ij  four  times  a  day),  iodoform 
(gr.  ^-ij  four  times  a  day),  and  antipyrine  (gr.  x-xx  three 
times  a  day)  are  all  occasionally  of  service.  The  alkaline 
waters  of  Carlsbad  and  Vichy  may  be  beneficial.  Jambul 
has  also  been  employed.  For  the  diabetic  coma,  venesec- 
tion and  intravenous  injections  of  a  3  per  cent,  solution  of 
sodium  bicarbonate  have  been  recommended  ;  but  recovery 
from  the  condition  is  exceedingly  uncommon. 

GLYCOSURIA. 

Sugar  may  be  found  in  the  urine  temporarily  under  the 
following  conditions  : 

1.  With  various  forms  of  poisoning,  such  as  that  by 
curare,  morphine,  amyl  nitrite,  alcohol,  chloroform,  chloral 
hydrate,  and  carbon  dioxide. 

2.  With  certain  infectious  diseases,  especially  diphtheria, 
cholera,  typhoid  fever,  and  epidemic  cerebro-spinal  meningitis. 


634        .W.l.Vr.lL    ()/■•   TI/J-:   PK.tCT/CK    OF  .]//■: D/C/.\7-:. 

3.  Gastro-intestinal  disorders  allowing^  of  faulty  digestion 
of  sugar  and  starches,  and  with  functional  disturbances  of  the 
liver. 

4.  In  gout)'  patients  with  chronic  diffuse  nephritis. 

5.  l-'rom  nervous  causes,  as  neuralgia,  concussion,  cerebral 
hemorrhage,  etc. 

6.  During  pregnancy. 

DIABETES  INSIPIDUS. 

Etiology. — Diabetes  insipidus  is  most  common  in  young 
adults,  especially  in  men;  it  not  infrequently  attacks 
children.  Congenital  cases  may  occur.  The  influence  of 
heredity  is  frequently  well  marked.  The  disease  has  fol- 
lowed injuries  and  diseases  of  the  brain  and  the  spinal  cord, 
infectious  diseases,  sun-stroke,  sudden  mental  excitement, 
and  the  rapid  drinking  of  large  quantities  of  fluid. 

Pathology. — The  exact  nature  of  the  disease  is  un- 
known ;  it  is  supposed,  however,  to  be  a  vaso-motor  dis- 
turbance of  the  renal  vessels,  or,  in  congenital  or  hereditary 
cases,  to  be  due  to  unnatural  permeability  of  the  blood- 
vessels of  the  Malpighian  tufts.  There  are  no  essential 
post-mortem  lesions. 

Symptoms. — The  disease  begins,  insidiously  or  sud- 
denly, with  the  excretion  of  an  increased  quantity  of  urine, 
of  low  specific  gravity.  From  five  to  ten  pints  daily  is  an 
average  quantity,  but  from  thirty  to  fort)'  pints  may  repre- 
sent the  daily  .secretion.  The  specific  gravity  of  the  urine 
varies  from  looi  to  1004.  Albuminuria  and  gl)'cosuria  are 
rare,  although  muscle-sugar,  or  inosite,  has  at  times  been 
found.  The  excretion  of  solids,  especially  of  urea  and  the 
phosphates,  may  be  increased  in  some  instances.  Thirst  is 
inordinate,  depending  upon  the  amount  of  urine  passed,  but 
the  appetite  is  rarely  excessive.  A  variety  of  hysterical  and 
neurasthenic  symptoms  may  appear,  but  grave  constitu- 
tional symptoms  are  usually  lacking. 

Prognosis. — Spontaneous  cure  results  in  a  few  instances. 
In  the  majority  of  cases  the  disease  is  intractable  to  treat- 
ment, although  it  does  not  tend  to  shorten  life. 

The  diagnosis  should  be  made  from  hysterical  polyuria, 


SCURVY.  635 

the  polyuria  of  nephritis,  and  diuresis  from  dru^s.  Dia- 
betes is  to  be  excluded  by  the  absence  of  glycosuria. 
Treatment  is  not  very  satisfactory.  The  most  reliable 
drug  seems  to  be  valerian  in  full  doses.  Ergot  has  been 
recommended,  but  large  doses  are  usually  required.  Good 
results  occasionally  follow  the  use  of  antipyrine  in  1 5 -grain 
doses  every  four  hours.  The  bromides  and  arsenic  have 
also  been  used  with  benefit.  The  constant  galvanic  current 
may  be  employed,  one  pole  being  applied  to  the  back  of 
the  neck,  the  other  pole  on  the  lumbar  region.  Codeine  is 
said  to  be  of  benefit,  but  the  danger  of  the  habit  should 
preclude  its  use.  In  severe  cases  benefit  may  follow  an 
exclusive  diet  of  meat  and  hot  water. 

SCURVY  (SCORBUTUS). 

Etiology. — Devastating  endemics  and  epidemics  of 
scurv)^  have  occurred  from  the  earliest  times  among  armies, 
among  sailors  on  long  cruises,  and  among  the  inhabitants 
of  besieged  cities,  but  the  disease  is  now  comparatively  rare. 
Sporadic  cases,  however,  are  not  infrequent,  and  the  disease 
attacks  young  children  more  frequently  than  is  usually 
supposed. 

Two  theories  as  to  scurvy  are  advanced  :  (i)  That  it  is  a 
dietetic  disease.  It  is  known  to  occur  from  bad  and  insuf- 
ficient food,  from  lack  of  variety  in  food,  and  from  lack  of 
fresh  vegetables.  Garrod  ascribes  the  disease  to  lack  of 
potassium  salts ;  while  Ralfe  believes  that  the  disease  is 
due  to  a  diminished  alkalescence  of  the  blood,  from  diminu- 
tion' of  vegetable  salts,  as  citrates,  oxalates,  and  lactates,  in 
the  food.  The  development  of  scurvy  is  regularly  favored 
by  poor  hygiene,  damp  dwellings,  lack  of  sunlight,  depre- 
ciated general  health,  depressing  mental  states,  and  over- 
exertion. The  disease  is  equally  distributed  between  the 
two  sexes.  (2)  The  infectious  theory  is  that  scurvy  is  due 
to  an  unknown  micro-organism,  and  that  the  dietetic  and 
hygienic  causes  are  only  factors  predisposing  to  infection. 

Patholog-y. — The  kidneys,  the  heart,  and  the  liver  show 
parenchymatous  degeneration.  The  spleen  is  enlarged  and 
soft.     Hemorrhages   are   found   beneath  the  skin,  beneath 


636        A/AXCAL    OF   THE    PRAC7/CF.    OF  MFPlCfXE. 

the  serous  and  mucous  membranes,  and  in  internal  orj^ans. 
Submucous  hemorrhages  may  lead  to   ulcerations. 

Symptoms. — The  onset  of  the  disease  is  usually  insid- 
ious, although  acute  cases  have  been  described.  The  symp- 
toms are  (i)  general  and  (2)  hemorrhagic. 

1.  Gciural  Symptoms. — There  are  increasing  weakness, 
pallor,  and  emaciation.  Palpitation  with  feeble  and  irregular 
heart-action  are  common,  and  a  haimic  murmur  usually  de- 
velops. Mental  depression  and  lassitude  become  extreme. 
The  temperature  is  rarely  elex'ated,  and  it  may  be  sub- 
normal. QEdema  of  the  ankles  may  be  observed.  The 
urine  is  usually  of  high  color  and  of  high  specific  gravity, 
and  the  phosphates  may  be  increased.  Albuminuria  is 
not  uncommon.  The  breath  is  foul.  The  bowels  are 
constipated. 

2.  Hemorrhagic  Sympto))is. — The  gums  become  spongy, 
tender,  and  bleed  readily.  These  changes,  however,  may  not 
be  observed  in  infants  and  in  old  people.  The  teeth  tend  to 
loosen  and  to  drop  out.  Ecchymoses  and  purpuric  spots  ap- 
pear in  the  extremities  and  spread  to  the  trunk;  they  may 
arise  .spontaneously  or  after  slight  traumatism.  Epistaxis 
is  common,  but  hemorrhages  from  the  lungs,  the  stomach, 
the  intestines,  and  the  kidnej^s  are  less  frequently  observed. 
Subperiosteal  hemorrhages  may  occur,  leading  to  pain, 
swelling,  and  immobility  in  the  affected  member,  and  ne- 
crosis of  bone  may  follow,  or  separation  of  the  epiph}'seal 
cartilage  may  result  in  young  children.  Paraplegia  or 
convulsions  may  be  due  to  cerebral  or  meningeal  hemor- 
rhage. 

Scurvy  in  children  requires  separate  mention.  The  fre- 
quent occurrence  of  infantile  scorbutus  in  America  has  been 
brought  to  our  notice  by  the  able  researches  of  Northrup  of 
New  York.  The  disease  occurs  in  infants,  usually  between 
the  ninth  and  fourteenth  months,  and  is  almost  regularly  due 
to  an  exclusive  diet  of  proprietary  food  or  of  condensed  milk. 
In  rare  instances  it  has  followed  the  use  of  milk  too  largely 
diluted.  There  is  no  evidence  that  sterilized  or  Pasteurized 
milk  can  originate  the  disea.se. 


SCUR  VY. 


637 


the 


fjums    are 


Symptoms. — The  child  becomes  anaemic,  irritable,  and 
cannot  bear  to  be  handled  or  touched.  The  .symptom.s 
of  rickets  may  coexist.  The  changes 
almost  constant,  although  they  may  not 
be  carried  to  an  extreme  degree.  The 
most  constant  symptom  of  infantile 
scorbutus  is  a  painful  fusiform  swelling 
of  the  lower  extremities,  usually  of  the 
thigh.  The  swelling  is  regularly  due  to 
.subperiosteal  hemorrhages.  The  skin 
over  the  swelling  is  usually  tense  and 
shiny,  is  not  hot  to  the  touch,  and  pitting 
on  pressure  does  not  occur.  The  tender- 
ness is  exquisite  and  is  increased  by 
motion.  As  the  swelling  subsides  thick- 
ening of  the  shaft  of  the  bone  may  be 
appreciated.  Fracture  of  the  bones  and 
separation  of  the  epiphyses  may  occur. 
Pseudo-paralysis  is  an  important  symp- 

.  -Fig.    53. — Vertical  section 

tom  ;    it  results  from    the  pain   caused  of  the  thigh  and  leg  m  a  case 
by  a  contraction  of  the  muscles  pulling  "^  '"^^"''^^  scorbutus.    The 

dark   areas   along  the  femur 

upon  their  tender  periosteal  attachment,  and  tibia  represent  subpen- 
There  may  be  purpura,  ecchymosis,  and  °^'""'  hemorrhage  (w.    p. 

J  >■         >■  •'  Northrup,  from   a  specimen 

hemorrhage   from  the  various   mucous  preserved  in  the  museum  of 
membranes.       Hematuria    may  be    an  theCoUegeofPhys.oansand 

■'  Surgeons). 

early  symptom  of  infantile  scorbutus. 

The  prognosis  is  good  if  proper  diet  and  hygiene  can  be 
enforced.  Death,  however,  may  result  from  weakness,  from 
heart  failure,  or  from  internal  hemorrhages. 

Treatment. — Sunlight,  fresh  air,  a  liberal  diet  of  vege- 
tables, and  orange-juice  are  sufficient  for  a  cure.  Orange- 
or  lemon-juice  is  almost  a  specific,  and  in  children  milk  and 
orange-juice  practically  constitute  the  treatment.  The  gums 
may  be  pencilled  with  a  strong  solution  of  nitrate  of  silver, 
or  mouth-washes  of  myrrh  or  astringents  may  be  used. 
Ansemia  is  to  be  controlled  by  iron,  fresh  air,  and  proper 
diet.  The  hemorrhagic  symptoms  are  to  be  treated  on  the 
principles  laid  down  under  the  consideration  of  purpura. 


638        MA.yr.lL    OF   THE   PRACTICE    OF  MEDIC/XE. 

RICKETS  (RACHITIS). 

Etiology. — Rickets  is  a  disease  of  the  first  and  second 
years  of  life,  and  is  rare  before  the  sixth  month,  although 
cases  of  congenital  rickets  have  been  described.  The  dis- 
ease occurs  especially  in  tenement-house  children,  from  the 
combined  effect  of  poor  air,  scanty  sunlight,  and  defective 
food.  The  most  common  of  the  dietetic  errors  that  may 
lead  to  the  disease  are  premature  weaning,  the  use  of  arti- 
ficial and  proprietary  foods,  especially  those  composed 
mainly  of  farinaceous  and  starchy  ingredients,  irregular 
feeding,  prolonged  lactation,  and  nursing  during  pregnancy. 
Children  of  weak  or  vicious  parentage  seem  to  be  predis- 
posed to  the  rachitic  condition.  The  disease  is  more  com- 
mon among  negroes  and  in  European  cities  than  among 
American  children.  The  connection  between  syphilis  and 
rickets  has  not  been  proven  satisfactorih-.  Rickets  is  often 
delayed  until  the  third  or  fourth  year,  and  then  may  appear 
as  a  sequel  to  some  infectious  disease  such  as  measles. 
The  disease  known  as  "acute  rickets"  is  now  supposed 
to  be  scorbutus. 

Pathology. — The  lesions  are  seen  in  their  fullest  develop- 
ment in  the  long  bones  and  in  the  ribs.  The  epiphyseal 
cartilages  undergo  rapid  proliferation,  and  form  thick,  soft 
cushions,  which  by  their  projection  may  present  evident 
bulging.  The  periosteum  strips  readily,  and  subperiosteal 
tissue  is  seen  to  be  soft  and  vascular,  resembling  spleen- 
pulp.  This  subperiosteal  thickening  is  best  marked  in  the 
middle  of  the  shaft  of  the  bones,  giving  to  them  a  spindle 
shape.  There  is  regularly  delay  or  arrest  of  ossification- 
proces.ses,  and  in  the  bones  the  organic  ingredients  may  be 
reduced  to  two-thirds  of  their  normal  proportions.  Rachitic 
bones  are  regularly  soft,  spongy,  and  vascular,  especially 
near  the  epiphyses  and  beneath  the  periosteum.  From  the 
bone -softening  various  deformities  arise — the  box-like 
cranium,  spinal  curvature,  deformed  pelvis,  knock-knee, 
bow-legs,  and  the  like.  In  time  there  occur  in  the  carti- 
lages and  in  the  subperiosteal  tissues  reconstructive  changes 
resembling  the  callus-growth  upon  fractures,  and  the  bones 


RfCKK  'PS.  639 

themselves  become  hard.  In  this  way  permanent  deformi- 
ties result.  The  liver  and  the  spleen  are  usually  enlarged 
in  rickets. 

Symptoms. — Certain  prodromal  symptoms  may  precede 
evident  changes  in  the  bones.  Gastro-intestinal  disorders 
are  usually  present,  and  a  peculiar  form  of  diarrhrta  limited 
to  the  first  part  of  the  day,  with  scanty  colorless  stools,  has 
been  described.  There  may  be  attacks  of  screaming  at 
night,  and  restlessness  with  an  intermittent  temperature  and 
splenic  enlargement.  Profuse  night-sweats  about  the  neck 
and  the  back  of  the  head  are  highly  suggestive  of  incipient 
rickets.  There  is  often  such  extreme  soreness  of  the  body 
that  the  child  cries  when  handled.  This  diffused  soreness 
is  a  most  suggestive  symptom.  The  child  becomes  flabby 
and  anaemic,  and  usually  emaciates.  There  may  be  "  pseudo- 
paresis,"  from  a  combination  of  muscular  weakness  and  dis- 
inclination to  move  on  account  of  the  general  soreness  and 
tenderness. 

Nervous  symptoms  often  are  present.  Attacks  of  spasm 
of  the  larynx  are  not  uncommon.  Convulsions,  either 
general  or  partial,  may  appear  at  intervals ;  the  convulsions 
may  be  fatal.  Tetany  and  carpopedal  spasms  may  be 
observed.      The  child  is   irritable  and   nervous. 

Symptoms  due  to  changes  in  the  bones  are  seen  first  in  the 
ankles,  wrists,  ribs,  and  cranium.  The  epiphyseal  ends  of 
the  bones  are  swollen ;  the  bones  are  liable  to  curvature, 
and  "  green-stick  "  fractures  may  be  caused  by  slight  injuries. 
Curvature  of  the  spine  (rachitic  scoliosis  and  kyphosis)  and 
pelvic  deformities  may  ultimately  result.  The  thorax  shows 
noticeable  changes.  The  swellings  at  the  junction  of  the 
ribs  with  their  cartilages  produce  visible  nodules,  to  which 
the  name  "rachitic  rosary"  has  been  applied.  The  lateral 
portions  of  the  thorax  are  frequently  drawn  inward  at  the 
portions  corresponding  with  the  insertion  of  the  diaphragm. 
"  Pigeon-breast "  may  occur.  The  changes  in  the  thorax 
may  be  so  marked  as  to  interfere  with  proper  chest-expan- 
sion, so  that  pulmonary  affections  trifling  to  the  non-ra- 
chitic  may  become  serious  diseases  in  these  children.  The 
clavicles  may  be  distorted  or  fractured. 


640        M-IXiAI.    OF   THE   rKACTICE    OF  MEDICIA'E. 

Characteristic  chancres  become  apparent  in  the  cranium. 
Tlie  fontanelles  remain  unclosed  until  the  second  or  third 
year  of  life,  and  the  occiput  may  be  so  thin  and  yielding 
that  it  can  bo  pressed  in  like  parchment.  To  this  latter 
condition  the  name  "  craniotabcs  "  has  been  applied.  The 
head  becomes  large  and  square.  The  occiput  is  flattened, 
the  biparietal  diameter  is  increased,  the  frontal  bones  are 
broad  and  prominent.  The  square,  box-like  cranium  may 
resemble  h\-drocephalus,  but  in  rickets  the  child  is  men- 
tall\'  bright. 

The  maxillary  bones  are  small  and  narrowed,  and  the 
vaulting  of  the  roof  of  the  mouth  is  increased.  Dentition 
is  late,  and  the  teeth  ma\'  be  ill  formed,  small,  or  irregularly 
crowded.  From  the  diminished  growth  of  the  bones  the 
child  may  be  stunted  and  dwarfed. 

The  prognosis  is  good  for  the  disease  itself,  but  many 
rachitic  children  fall  victims  to  gastro-intestinal  or  pulmon- 
ary disorders.  The  prognosis  should  also  regard  the  ulti- 
mate effect  of  the  thoracic  spinal  and  pelvic  deformities. 

Treatment. — The  most  important  treatment  is  improve- 
ment of  the  general  condition  by  proper  diet,  good  air,  sun- 
shine, and  salt-water  baths.  Carbohydrates  should  be  re- 
duced to  a  minimum,  the  diet  consisting  of  nitrogenous 
foods  and  fats,  such  as  red  meats,  milk,  cream,  eggs,  and 
fruit.  Cod-liver  oil  is  of  service  in  nearly  every  case.  Anae- 
mia is  to  be  treated  by  syrup  of  the  iodide  of  iron,  and  di- 
gestive disturbances  should  receive  prompt  attention.  The 
child  should  lie  on  a  hair  mattress  or  pillow,  and  should  not 
be  allowed  to  walk  so  long  as  the  bones  are  soft.  Theoreti- 
cally, preparations  of  lime,  such  as  calcium  lactophosphate, 
are  indicated,  but  as  a  matter  of  experience  they  do  very 
little  good.  The  drug  par  excclloicc  is  phosphorus,  which 
should  be  given  in  doses  of  gr.  yi^-  three  times  a  day  in  cod- 
liver  oil.  The  deformities  ultimately  require  special  g}minas- 
tic  exercises  for  their  correction,  or  orthopajdic  treatment. 

PURPURIC  DISEASES. 

Under  this  heading  are  included  a  number  of  diseases 
having   one   symptom    in    common — the    extravasation    of 


PURPURIC  DISEASES.  64 1 

blood  under  the  skin.  Small  hemorrhagic  spots  are  known 
as  "  petechiae  ;"  larger  hemorrhages  are  called  "  echymoses." 
Various  degrees  of  intensity  are  met  with  in  each  variety  of 
purpuric  disease.  The  mildest  form  consists  of  subcuta- 
neous hemorrhages  alone  ;  the  severer  forms  include  as  well 
hemorrhages  from  free  mucous  surfaces  and  visceral  hemor- 
rhages. Thus  purpura  may  be  a  trifling,  a  serious,  or  even 
a  fatal  disease.  The  following  classification  may  be  adopted, 
although  it  should  be  remembered  that  transitional  forms  are 
frequently  encountered:  i.  Symptomatic  purpura;  2.  Pur- 
pura rheumatica;  3.  Purpura  heemorrhagica. 

Symptomatic  Purpura. 

1.  Toxic  cases  folloiviiig  certain  drugs,  such  as  potassium 
iodide,  chloral  hydrate,  quinine,  copaiba,  and  more  rarely 
ergot,  mercury,  and  belladonna. 

2.  Severe  infectious  diseases,  such  as  acute  yellow  atro- 
phy of  the  liver,  snake-bites,  typhoid  fever,  pneumonia, 
and  the  exanthemata. 

3.  Severe  cow\\x\.\xq.6,  jaundice. 

4.  Profound  ancsniia,  leukcemia,  pseudo-leukmmia,  scui"vy, 
and  exhausted  and  cachectic  conditions. 

5.  Nezv-born  children  zvitJi  congenital  syphilitic  change  in 
the  a^'terial  zvalls. 

6.  Nezv-born  children  zvitJiout  arterial  change.  This  form 
occurs  in  i  per  cent,  of  children,  with  a  mortality  of  75  per 
cent. 

7.  Embolic  cases  with  malignant  endocarditis  and  with 
multiple  sarcoma. 

8.  Neurotic  cases,  from  vaso-motor  relaxation  or  enfeeble- 
ment  of  the  arterial  walls,  after  fright,  deep  emotion, 
hysteria,  hypnotism,  severe  neuralgias,  and  inflammations 
of  the  spinal  cord. 

Symptoms. — Secondary  purpura  may  occur  with  sub- 
cutaneous hemorrhages  alone,  or  with  free  and  visceral 
hemorrhages  as  well.  Arthritic  pains  may  occur  as  in 
purpura  rheumatica. 

4] 


642        M.lXr.lL    OF    rUE    PNACnCE    OF  MEDICINE. 

Purpura  Riieumatica  (Peliosis  Rheumatica,  or 
Schonlein's  Disease). 

This  affection  is  most  common  between  the  ages  of 
twenty  and  thirty,  and  is  more  frequent  in  males  than  in 
females.  An  antecedent  history  of  rheumatic  fever  is  fre- 
quently obtained,  but  the  exact  relationship  of  the  disease 
to  rheumatism  has  not  been  determined  satisfactorily. 

Symptoms. — The  disease  usually  begins  with  a  sore 
throat,  malaise,  moderate  fever,  and  pain  in  the  joints.  The 
gums  are  not  affected  as  in  scurvx-.  The  articular  pain  and 
swelling  are  due  to  small  hemorrhages  in  and  about  the 
joints.  More  rarely  arthritis  with  serous  or  hemorrhagic 
effusion  occurs.  Purpura  precedes  or  accompanies  the 
articular  pains,  and  there  are  frequently  associated  urticarial 
wheals  which  may  be  hemorrhagic,  or  any  of  the  manifesta- 
tions of  erythema.  Hemorrhagic  pemphigus  may  also  occur. 
The  urine  may  contain  albumin. 

The  duration  of  the  disease  is  between  ten  days  and 
three  weeks.  Relapses  are  common,  especially  if  the  patient 
walk  too  soon. 

The  prognosis  is  perfectly  good. 

Purpura  H.emorrhagica  (Morbus  Maculosus,  or 
Werlhoff's  Dlsease). 

Under  this  heading  are  included  cases  of  purpura  having 
a  disposition  to  bleed  from  the  mucous  membranes  and 
into  internal  viscera.  Severe  cases  of  secondary  purpura 
may  be  thus  included.  In  some  cases  purpura  haemor- 
rhagica  runs  a  course  more  like  that  of  an  infectious 
disease.     An  acute  and  a  subacute  form  may  be  described. 

Acute  Purpura  H.emorrhac.ica  (Fulminating  Purpura). 
— The  acute  form  is  more  common  in  young  adults,  but  is 
a  rare  condition. 

I.  In  some  cases  the  patient  is  seized  with  a  chill,  fever 
rising  to  103°  or  104°  F.,  and  intense  prostration.  Purpuric 
spots  rapidly  appear,  and  bleeding  occurs  from  any  of  the 
mucous  membranes.  The  patient  pa.sses  into  stupor  alter- 
nating with  restlessness  and  mild  delirum,  and  dies,  either 
from  the  hemorrhages  or  in  coma,  in  from  one  to  seven 


PUR/'lJ/aC  DISEASES.  643 

days.     The  prognosis  is  bad,  75  per  cent,  of  all  cases  ter- 
minating fatally. 

2.  In  other  cases  the  visceral  hemorrhages  are  the  excit- 
ing cause  of  death.  Cerebral  and  meningeal  hemorrhages 
are  usually  multiple  and  show  no  favorite  seats  of  selection. 
Hemorrhage  into  the  suprarenal  capsules  may  cause  death 
in  collapse  within  a  few  hours. 

3.  When  the  disease  attacks  pregnant  women,  miscar- 
riage and  severe  post-partum  hemorrhage  result,  and  the 
disease  runs  a  rapid,  and  usually  a  fatal,  course. 

Symptoms. — Subacute  Purpura  H.emorrhagica. — 
Prodromal  symptoms  may  precede  the  actual  onset ;  these 
symptoms  comprise  malaise,  chilly  feelings,  and  a  slight 
evening  rise  in  temperature. 

Constitutional  Symptoms. — An  initial  chill  may  occur,  but 
usually  chilly  feelings  are  scattered  throughout  the  course 
of  the  disease.  The  temperature  varies  from  100°  to  104°  F., 
and  is  higher  in  severe  cases  and  in  children.  Prostration 
is  a  marked  and  constant  symptom,  and  usually  persists 
during  convalescence.  In  severe  cases  the  "  typhoid  con- 
dition "  may  be  developed,  and  in  this  condition  the  patient 
may  die.  The  spleen  and  the  liver  are  usually  enlarged 
during  the  attack,  and  a  light  form  of  jaundice  is  not  un- 
common.    The  blood  rapidly  shows  the  changes  of  anaemia. 

Hemorrhagic  Symptoms. — Purpura  develops,  the  hemor- 
rhagic areas  varying  from  pin-head  size  to  that  of  the  palm 
of  the  hand.  Extensive  ecchymoses  may  be  followed  by 
gangrene  of  the  skin.  Free  hemorrhages  occur  from  any 
of  the  mucous  membranes,  the  most  frequent  sources  of 
bleeding  being  respectively  the  nose,  the  kidney,  the  intes- 
tines, and  the  uterus.  These  hemorrhages  may  be  moder- 
ate, or  they  may  be  so  profuse  as  to  induce  a  fatal  anaemia. 
Internal  hemorrhages  into  the  brain  and  its  membranes,  the 
lungs,  or  the  adrenals  may  occur,  but  they  are  not  as  com- 
mon as  in  the  acute  form.  Pain  and  swelling  of  the  joints, 
especially  of  the  hands,  the  feet,  and  the  knees,  may  be  ob- 
served. The  articular  symptoms  are  identical  with  those 
seen  in  peliosis  rheumatica.  In  rare  cases  ankylosis  or 
arthritis  may  develop.     The  gums  may  be  normal,  or  they 


644        .^/.l.yC.lA    OJ--   THE   PRACTICE    OE  MEDICLVE. 

may  be  swollen  and  may  bleed,  but  the  teeth  are  not  loos- 
ened as  in  scurvy. 

The  pathology  of  the  disease  is  unknown.  Letzerich 
has  described  a  bacillus  which  grows  in  the  liver  and  enters 
the  blood-vessels,  causing  in  the  smaller  vessels  hyaline 
thrombi  which  so  weaken  the  internal  wall  as  to  allow  of 
hemorrhage;  but  his  experiments  have  not  been  sufficiently 
verified. 

The  duration  of  the  disease  varies  from  several  days  to 
several  weeks,  but  b\'  relapses  the  disease  may  be  protracted 
for  months  or  e\'en  for  years. 

The  prognosis  is  usually  good,  but  death  may  result 
from  anaemia,  from  fatt}-  degeneration  of  the  heart,  from 
exhaustion,  or  from  visceral  hemorrhages. 

HoioclCs  Disease. — A  severe  form  of  subacute  purpura 
haemorrhagica  has  been  described  by  Henoch  and  bears  his 
name.  This  form  occurs  especially  in  children  between  the 
ninth  and  twelfth  years,  although  it  has  occurred  between 
the  ages  of  three  and  forty-six.  Males  are  affected  five 
times  as  frequently  as  females.  There  is  a  prodromal  period 
with  malaise,  slight  fever,  and  pain  in  the  joints.  The  onset 
is  characterized  by  purpura,  pain  and  swelling  of  the  joints, 
and  severe  gastro-intestinal  s}^mptoms.  These  latter  symp- 
toms consist  of  abdominal  tenderness  with  a  colicky  pain 
of  great  severit\\  The  abdomen  is  rigid  and  retracted. 
Rectal  tenesmus  occurs,  with  bloody  stools.  Vomiting  is 
severe,  and  the  vomited  matters  may  contain  blood.  These 
gastro-intestinal  symptoms  seem  to  be  due  to  hemorrhages 
in  the  submucosa  or  to  hemorrhagic  infarcts  of  the  small 
blood-vessels  of  the  intestinal  wall.  Intestinal  ulceration, 
perforation,  and  peritonitis  ma\'  result.  The  spleen  is 
enlarged.  The  temperature  is  slightly  raised.  Haematuria 
occurs  in  one-fifth  of  the  cases.  These  symptoms  continue 
for  a  few  days  and  then  subside,  but  relapses  are  the  rule^ 
and  as  many  as  twenty  subsequent  attacks  have  been  de- 
scribed.    The  nature  of  the  disease  is  unknown. 

The  prognosis  is  fairly  good,  being  better  in  children 
(5  per  cent,  mortality)  than  in  adults,  of  whom  25  per  cent, 
die. 


IlyKMOPIIIfJA.  645 

Treatment  of  Purpuric  Diseases. 

In  the  secondary  purpuras  the  treatment  should  be 
directed  toward  the  excitini:^  causes.  In  the  other  forms  the 
treatment  is  supporting  and  symptomatic.  Arsenic  in  full 
doses  is  at  times  of  service.  Iron  is  indicated  for  anaemic 
conditions,  but  it  should  be  withheld  during  the  acute 
attacks,  as  it  seems  to  increase  the  liability  to  hemorrhage. 
In  all  cases  fresh  air,  good  food,  and  a  tonic  supporting 
treatment  are  indicated.  The  salicylates  are  at  times  of 
service  in  peliosis  rheumatica,  but  in  sorne  cases  they  seem 
useless. 

For  the  hemorrhages  various  drugs  may  be  used,  but  no 
one  hemostatic  can  be  relied  upon.  Among  the  drugs  used 
are  aromatic  sulphuric  acid,  turpentine,  acetate  of  lead,  and 
gallic  acid.     Epistaxis  may  require  plugging  of  the  nares. 

Menorrhagia  may  be  controlled  by  firm  tamponage. 

In  acute  purpura  free  stimulation  is  necessary,  and  in 
case  of  profuse  hemorrhage  rectal  or  hypodermic  injections 
of  sterilized  saline  solutions  should  be  employed. 

In  subacute  purpura  much  benefit  may  be  derived  from  a 
change  of  climate,  inland  places  where  the  air  is  dry  and 
bracing  being  preferable. 

HEMOPHILIA. 

Etiolog-y, — By  "  haemophilia  "  is  meant  a  constitutional 
inherited  tendency  to  uncontrollable  bleeding.  The  disease 
appears  in  males  in  the  proportion  of  13  :  i.  Females  rarely 
suffer,  although  the  female  members  of  a  bleeding  family 
transmit  the  tendency  to  their  male  offspring.  Paternal 
transmission  is  exceedingly  rare.  In  rare  instances  the 
tendency  is  acquired. 

Pathology. — The  exact  nature  of  the  disease  is  unknown. 
An  unusual  thinness  of  the  arterial  walls  has  been  observed, 
but  this  condition  is  inconstant.  The  joints  may  be  found 
to  be  the  seat  of  hemorrhages,  and  inflammation  of  the  syno- 
vial capsule  has  been  described  in  a  few  instances. 

The  symptoms  generally  appear  in  early  childhood,  al- 
though excessive  bleeding  does  not  usually  accompany  the 


646        MAXL'AI.    OF   THE   PRACTICE    OF  MEDICIXE. 

cutting:  of  tlie  umbilical  cord.  The  symptoms  consist  of 
licmorrhages  and  inflammation  of  the  joints.  The  hemor- 
rhages may  be  spontaneous  or  nia)-  follow  traumatism. 
Cuts,  or  abrasions  bleed  profuseK',  and  continuous  capillary 
oozing  may  continue  for  da)-s  after  the  extraction  of  teeth. 
Epistaxis  is  couunonly  profuse.  These  hemorrhages  weaken 
the  patient  and  may  at  any  time  prove  fatal.  Subcutaneous 
hemorrhages  evince  themselves  as  purpuric  spots,  ecchy- 
moses,  and  hrematomata.  Large  ecchymoses  may  be  suc- 
ceeded by  gangrene.  In  the  female  menstruation  may  be 
profuse,  but  parturition  is  rarely  complicated  by  hemor- 
rhage. The  joint-symptoms  usually  occur  after  exposure 
to  cold,  to  which  hajmophilic  patients  are  exceedingly  sus- 
ceptible. Pain  and  swelling  occur,  especially  in  the  larger 
joints,  and  the  condition  may  closely  resemble  rheumatism. 

Prognosis. — Haemophilia  is  a  contant  menace  to  life. 
Half  the  cases  die  before  the  seventh  year,  and  only  one- 
eighth  reach  majority.  The  younger  the  patient  the  more 
serious  the  prognosis.  The  prognosis  is  better  in  girls 
than  in  boys.  Although  a  serious  condition,  haemophilia 
is  not  inconsistent,  in  some  instances,  with  a  prolonged  and 
busy  life. 

Treatment. — Sons  born  to  female  members  of  bleeding 
families  should  be  protected  from  external  injuries,  and  the 
system  should  be  fortified  by  fresh  air  and  general  hygiene. 
Surgical  operations,  however  slight,  should  be  resorted  to 
only  when  absolutely  indicated,  and  every  appliance  should 
be  at  hand  to  check  hemorrhage.  The  hemorrhages,  when 
they  occur,  should  be  treated  by  compression  and  by  the 
application  of  the  well-known  haemostatic  remedies.  For 
the  joint-affections  rest  and  soothing  applications  are  in- 
dicated. 


VIL   DISEASES  OF  THE  BLOOD  AND 
THE  LYMPHATIC  GLANDS, 


ANEMIA. 

Anemia  is  a  generic  name  applied  to  deficiencies  in  the 
quality  or  quantity  of  the  blood  or  of  its  important  constitu- 
ents. The  quantity  of  the  blood  may  be  diminished  (oligae- 
mia),  or  the  number  of  the  red  corpuscles  may  alone  be 
diminished  (oligocythasmia).  In  other  cases  such  important 
constituents  as  albumin  or  haemoglobin  may  suffer  diminu- 
tion (oligochromaemia).  The  following  classification  of 
anaemia  is  generally  adopted:  i.  Secondary  anaemia;  2. 
Chlorosis;  3.  Pernicious  anaemia. 

Secondary  Anemia. 
Etiology. — The  causes  of  secondary  anaemia  have  been 
conveniently  classified  by  Osier  as  follows  : 
.1.  AncBmia  from  lievion'liage. 

2.  Loiig-contimicd  drain  on  tJie  albiiniinons  materials  of  the 
blood,  as  in  chronic  suppuration,  Bright's  disease,  prolonged 
lactation,  or  rapid-growing  tumors,  as  cancer. 

3.  AncEniia  from  inaniiioji  and  defective  nutrition,  as  from 
insufficient  or  improper  food,  digestive  disturbances  causing 
malassimilation,  improper  modes  of  life,  and  intestinal 
parasites. 

4.  Toxic  ancemia  results  from  the  use  of  certain  drugs,  as 
lead,  mercury,  arsenic,  salicylic  acid,  or  from  organic  poison- 
ing, as  in  syphilis,  malaria,  infectious  diseases,  tuberculosis, 
and  pyrexia. 

Pathology. — In  secondary  anaemia  the  number  of  the 
red  corpuscles  and  the  percentage  of  haemoglobin  are  pro- 
portionately diminished.  In  severe  forms  some  of  the  cells 
may  be  unnaturally  small  (microcytes)  or  of  irregular  sizes 

647 


648        M.lXr.lL    OF   THE   PKACTJCE    OF  MEDICINE. 

(poikilocytcs).  Nucleated  red  cells  arc  always  found,  al- 
though their  number  may  be  small  in  the  mildest  grades 
of  anivmia.  In  an;emia  after  hemorrhage  a  primary  in- 
crease in  the  number  of  the  white  corpuscles  is  usually 
noticed.  The  restoration  of  the  watery,  saline,  and  albu- 
minous materials  rapidly  occurs  by  absorption,  but  the 
regeneration  of  the  red  cells  is  a  slower  process.  Restora- 
tion of  the  normal  percentage  of  haemoglobin  is  the  last 
process  of  regeneration. 

General  Symptomatology  of  Anaemia. —  i.  Pallor  oi\}i^Q 
skin  and  the  mucous  membranes.  It  must  be  remembered 
that  not  all  ana.»mic  patients  are  pale,  and  that  not  all  pale 
patients  are  anaemic.  Ana.'mic  pallor  is  best  appreciated 
by  the  colorless  appearance  of  the  ears.  In  suspected  cases 
of  anaemia  more  reliance  should  be  placed  upon  the  results 
obtained  by  counting  the  red  blood-cells  and  estimating  the 
percentage  of  haemoglobin  than  upon  the  appearance  of 
the  patient. 

2.  Cardiac  Symptoms. — The  pulse  is  rapid  and  usually 
of  low  tension.  Occasionally  a  high-tension  pulse  is  en- 
countered. The  heart-action  is  irritable.  Palpitation  and 
syncopal  attacks  are  common.  In  acute  anaemia  death  from 
syncope  may  occur.     The  heart,  being  supplied  with  blood 

'  of  poor  quality,  tends  to  become  fatty  and  loses  its  muscular 
tone.  Mild  grades  of  dilatation  are  common.  A  systolic 
haemic  murmur  ma\'  be  heard  over  the  pulmonary  area  and 
is  transmitted  upward.  This  murmur  comes  and  goes,  and 
is  often  appreciated  only  while  the  patient  lies  down.  The 
origin  of  the  anaemic  murmur  is  obscure.  There  may  be 
heard  at  the  apex  a  systolic  murmur  transmitted  to  the 
axilla.  This  murmur  arises  from  relati\'e  mitral  insufficienc}'- 
occasioned  by  poor  muscular  contraction,  or  from  slight 
dilatation  of  the  left  ventricle.  A  continuous  venous  hum 
(the  bruit  de  diablc)  may  be  heard  over  the  jugular  vein  on 
the  right  side  of  the  neck.  In  extreme  anaemia  there  is  a 
tendency  to  thrombus-formation,  especially  in  the  femoral 
vein.  Unless  thrombus  occur  in  the  cerebral  sinuses,  the 
condition  is  not  serious. 

3.  Dyspeptic  syuiptoins  are  rarely  absent.     The  tongue  is 


AN/KMFA.  649 

flabby  and  coated.     The  bowels  are  constipated ;  the  appe- 
tite is  irregular  and  capricious, 

4.  Piilinonary  Symptoms. — Dyspncea  on  exertion  is  in 
proportion  to  the  extent  of  the  anaemia  and  the  rapidity 
of  its  development.  In  acute  anaemia  from  hemorrhage 
there  may  be  "  air-hunger."  A  slight  cough  without  expec- 
toration not  infrequently  occurs. 

5.  Cerebral  Symptoms. — There  is  regularly  mental  apathy 
and  loss  of  the  power  of  concentrating  the  mind.  Spots  be- 
fore the  eyes,  buzzing  noises  in  the  ears,  and  vertigo  indicate 
cerebral  anaemia,  whether  of  general  or  local  origin.  Head- 
aches, usually  more  marked  in  the  top  of  the  head  and 
increased  by  standing,  are  frequent,  but  other  forms  of 
headache  due  to  digestive  disturbances  are  commonly  en- 
countered. 

6.  There  are  body-weakness  and  lack  of  endurance.  The 
inability  to  exercise  is  often  aggravated  by  the  dyspnoea 
thus  induced.  Slight  oedema  of  the  ankles  or  the  legs  is  not 
uncommon.  An  irregular  low  temperature  may  be  noted 
in  severe  cases.  Emaciation  does  not  belong  to  simple 
anaemia.  If  present,  some  primal  cause,  as  tuberculosis  or 
cancer,  should  be  suspected. 

7.  Menstruation  is  often  affected.  There  may  be  menor- 
rhagia,  but,  as  a  rule,  the  menses  become  scanty  and  light- 
colored  or  may  even  cease.  Amenorrhoea  is  of  no  signifi- 
cance and  demands  no  special  treatment,  as  it  is  nature's 
method  of  preventing  further  drains  upon  the  already  im- 
poverished blood. 

8.  Nervous  and  liysterical  symptoms  are  usually  present. 
The  patient  becomes  irritable  and  restless,  sleepless  by 
night,  drowsy  by  day,  and  may  complain  of  various  nervous 
symptoms,  such  as  hot  and  cold  flashes,  irregular  pains,  and 
curious  sensations  in  the  skin. 

The  diagnosis  of  anaemia  is  rendered  positive  by  the 
results  of  blood-examination.  For  methods  of  counting 
the  corpuscles  and  of  calculating  the  percentage  of  haemo- 
globin the  reader  is  referred  to  books  on  clinical  diagnosis. 
The    diaenosis    should    never    rest    with    the   detection   of 


650        MAXr.lL    c'/    JJJK    rK.ICT/CE    OF  MEDICINE. 

anaemia,  but  must  extend  to  the  discovery  of  the  cause,  to 
which  the  blood-condition  is  secondar\-. 

Treatment. — The  primal  cause,  if  possible,  should  be  re- 
moved by  correcting  improper  modes  of  life  and  controlling 
digestive  errors  and  constipation.  The  \alue  of  fre.-;h  air 
and  sunlight  cannot  be  over-estimated,  but  it  is  equally  im- 
portant not  to  over-fatigue  annemic  patients  by  keeping  them 
walking  or  exercising  all  day,  as  is  sometimes  done. 

The  specific  drug  for  anaemia  is  iron.  The  special  prep- 
aration used  should  not  be  such  as  to  cause  constipation 
or  headache.  The  preparations  recommended  are  Blaud's 
pill  (gr.  V,  t.  i.  d.),  tartrate  of  iron  and  potassium  in  lo-grain 
doses  in  water  and  glycerin  (Price's  English  glycerin  should 
be  used),  citrate  of  iron  and  quinine,  the  pyrophosphate  of 
iron,  and  the  liquor  ferro-mangans  of  Gude  or  of  Dietrich. 
During  the  administration  of  iron  the  bowels  must  be  moved 
daily,  preferably  by  salines  given  in  the  morning.  Should 
iron  not  be  well  borne,  arsenic  or  small  doses  of  bichloride 
of  mercurx'  or  of  binoxide  of  manganese  may  be  given. 
In  severe  cases  rest  in  bed  at  the  beginning  of  the  treat- 
ment is  to  be  recommended. 

Chlorosis. 

Etiolog-y  and  Symptoms. — This  condition  is  common  to 
women  between  the  ages  of  fourteen  and  twenty-four. 
More  rarely  the  affection  is  encountered  in  males  at  the  age 
of  puberty.  Blondes  are  more  frequently  attacked  than  bru- 
nettes. The  disease  is  especially  frequent  in  over-worked 
factory-girls  who  live  amid  poor  hygienic  surroundings  and 
who  work  hard  upon  insufficient  or  improper  food ;  but 
cases  among  the  upper  classes  are  not  unconmion.  Young 
female  immigrants  are  often  attacked  soon  after  their  arrival 
in  America.  There  seems  to  be  some  connection  between 
chlorosis  and  puberty,  as  in  many  cases  there  is  the  history 
of  precocious  development  and  the  early  appearance  of  the 
menses ;  in  other  cases  the  menses  may  be  retarded.  Sir 
Andrew  Clark  attributed  chlorosis  to  a  blood-poisoning 
from  the  absorption  of  toxic  products  from  a  constipated 
bowel.     In  some  cases  it  would  seem  that  chlorosis  had  a 


ANyJiMIA.  65 1 

primary  nervous  orig'in.  Mothers  chlorotic  in  their  youth 
are  apt  to  beget  clilorotic  daughters.  In  a  few  instances 
chlorosis  seems  to  be  due  to  a  congenital  lack  of  develop- 
ment of  the  arterial  system  (Virchow).  Synonyms :  Chloro- 
ansemia ;  Green  sickness. 

Pathology. — The  essential  blood-change  consists  in  the 
reduction  of  haemoglobin.  In  average  cases  the  haemoglobin 
falls  to  40  per  cent,  in  severe  cases  to  20  per  cent.  The 
number  of  the  red  cells  may  be  normal,  although,  as  a  rule, 
they  are  considerably  reduced,  but  never  to  the  same  pro- 
portional extent  as  the  haemoglobin.  In  a  series  of  63 
cases  reported  by  Osier  the  average  reduction  in  the  num- 
ber of  red  cells  was  74  per  cent. ;  the  average  quantity  of 
the  haemoglobin  was  42.3  per  cent.  Poikilocytes,  micro- 
cytes,  and  a  small  number  of  nucleated  red  blood-cells  may 
be  seen. 

Symptoms. — Anaemic  symptoms  are  constant,  especially 
those  of  nervous  and  dyspeptic  origin.  Amenorrhoea  is 
most  commonly  observed.  The  color  of  the  skin  is  not 
that  of  anaemia,  but  is  a  pale  greenish-yellow  that  is  quite 
characteristic. 

There  has  been  described  a  gastric  type  of  chlorosis  with 
nausea,  vomiting,  and  epigastric  pain  as  prominent  symptoms. 
There  may  even  be  vomiting  of  blood,  so  that  the  case  may 
resemble  one  of  gastric  ulcer,  The  diagnosis  in  these  cases 
from  gastric  ulcer  is  often  one  of  great  difficulty,  and  is 
rendered  more  uncertain  by  the  fact  that  gastric  ulcer  not 
uncommonly  occurs  in  chlorotic  women. 

The  appetite  is  apt  to  be  capricious  and  is  even  perverted. 
Constipation  is  usually  constant  and  obstinate.  Emaciation 
does  not  occur.  CEdema  of  the  ankles  may  be  noticed, 
and  there  may  be  an  irregular  fever.  The  cardiac  symp- 
toms of  anaemia  are  usually  well  marked. 

The  prognosis  is  good  for  recovery,  but  relapses  are 
common,  and  by  them  the  course  of  the  disease  may  be 
prolonged.  Relapses  may  occur  even  during  the  third 
decade  of  life. 

Treatment  is  usually  followed  by  brilliant  results  if  the 
patient    faithfully    carries    out    the    directions.       Iron    is    a 


652        MAXLAL    OF  THE   PRACTICE    OF  iVEDICIXE. 

specific,  and  under  its  use  the  haenio<;"lobin  increases  from  5 
to  10  per  cent,  eacli  week.  The  patient  rapidly  improves 
under  its  use,  and  often  feels  capable  of  discontinuincj  the 
treatment,  but  it  is  important  to  continue  treatment  until  the 
hjemoglobin  is  above  90  per  cent.,  as  otherwise  the  ]:)atent 
is  apt  to  relapse.  The  cure  in  average  cases  is  obtained  by 
about  three  months"  treatment. 

Fresh  air,  good  nourishing  food,  improved  hygiene,  and 
the  daily  use  of  laxatives,  if  needed,  are  important  adjuvants 
to  the  medicinal  treatment.  In  severe  cases  a  short  rest  in 
bed  at  the  beginning  of  the  treatment  is  often  of  incalcula- 
ble service.  In  the  chlorosis  of  young  immigrants  per- 
oxide of  manganese  or  permanganate  of  potassium  in  2- 
grain  doses  three  times  a  day  may  be  advantageously  com- 
bined with  the  iron. 

Pernicious  Anemia. 

Synonyms. — Essential  anaemia  ;  Idiopathic  anaemia. 

Under  the  heading  "pernicious  anaemia"  are  included 
cases  of  anaemia  running  a  progressive  course  and  not  due 
to  any  evident  cause.  Severe  secondary  anaemia,  resem- 
bling the  pernicious  form  in  its  clinical  features,  may  follow 
atrophy  of  the  stomach  and  certam  intestinal  parasites, 
especially  the  bothriocephalus  latus  and  the  ankylostoma 
duodenale,  but  it  is  doubtful  whether  these  secondary  cases 
are  to  be  considered  as  examples  of  the  true  pernicious 
ana:;mia. 

Etiology. — The  disease  is  one  of  adult  life;  more  rarely 
it  attacks  children.  Both  sexes  are  equally  affected.  In 
some  cases  there  is  a  history  of  pregnancy  or  of  parturition  ; 
in  other  cases  no  assignable  cause  for  the  an;emia  can  be 
found. 

Pathology. — The  essential  lesions  are  found  in  the  blood, 
the  liver,  and  the  bone-marrow. 

The  blood  is  diminished  in  quantity  and  is  ])ale  and 
watery.  The  number  of  the  red  blood-corpuscles  is  greatly 
reduced,  in  some  instances  to  as  low  as  one-tenth  or  less  of 
their  normal  number  (500,000  to  the  cubic  millimeter  is  not 
an  uncommon  reduction  ;  in  one  instance  the  number  was 


ANyKMJA.  653 

reduced  from  the  normal  5,000,000  to  143,000).  The  per- 
centage of  haemoglobin  may  be  reduced  in  proportion  to 
the  reduction  in  the  number  of  the  red  cells,  or  it  may  even 
be  relatively  increased.  It  is  pathognomonic  of  pernicious 
anaemia  that  each  red  corpuscle  remaining  in  the  blood 
carries  Its  normal,  or  even  more  than  its  normal,  load  of 
haemoglobin.  Large  and  small  red  corpuscles  are  seen  in 
the  freshly  drawn  blood  ("  megalocytes "  and  "  micro- 
cytes  "),  and  the  corpuscles  may  be  deformed,  flask-shaped, 
and  distorted  ("  poikilocytes ").  Nucleated  red  cells  are 
constantly  present,  and,  if  present  in  large  numbers,  are  dis- 
tinctive only  of  pernicious  anaemia  and  of  the  last  stages  of 
leukaemia.  In  dried  and  stained  specimens  of  blood  two 
varieties  of  nucleated  cells  are  seen — one  normal  in  size, 
with  a  sharply  defined  nucleus  ("  normoblast "),  and  others 
of  large  size,  with  large,  poorly-stained  nuclei  ("  giganto- 
blasts ").  The  leucocytes  are  generally  diminished  in 
number. 

The  liver  may  be  enlarged  and  fatty.  The  peripheral 
zones  of  the  acini  are  pigmented  by  iron — a  condition,  in  all 
probability,  characteristic  of  pernicious  anaemia. 

The  boiie-viarrozv  shows  an  increase  of  lymphoid  and  nu- 
cleated red  cells,  and  resembles  the  red  marrow  of  the  child. 

There  is  found  fatty  degeneration  of  the  heart,  the 
kidneys,  and  the  intima  of  the  smaller  blood-vessels.  The 
spleen  may  be  normal  or  slightly  enlarged,  and  may  be 
pigmented  by  iron.  The  lymphatic  glands  may  resemble 
spleen-pulp  in  consistency  and  color.  Hemorrhages  are 
usually  found  under  the  skin  and  the  mucous  and  serous 
membranes. 

Two  theories  of  pernicious  anaemia  have  been  advanced : 

1.  Hunter  maintains  that,  by  reason  of  faulty  gastro- 
intestinal digestion,  toxic  products  gain  access  to  the  liver 
and  cause  extensive  blood-destniction,  with  the  deposit  of 
pigment  in  the  liver  and  the  passage  of  urobilin  by  the 
kidneys.  Hunter's  views,  although  not  absolutely  proven, 
are  those  generally  adopted. 

2.  The  second  theory  is  that  there  is  an  increased  ten- 


654        M.lXi'AL    OF   THE   J' K  AC  TICK    OF  MEDICIXE. 

derness  or  vulnerability  of  the  blood-corpuscles,  from  faulty 
processes  in  blood-manufacture. 

The  symptoms  are  those  of  progressive  anaemia.  The 
color  of  the  patient  is  a  peculiar  waxy  white  or  pale  lemon. 
The  fat  is  usually  well  preserved,  and  the  patient  presents  a 
bloated  appearance.  Syncopal  attacks  are  frequent,  and  fatal 
s\-ncope,  from  fatty  degeneration  of  the  heart,  may  occur. 
In  some  cases  capillary  pulsation  and  visible  pulsation  of  the 
arteries  may  be  as  well  marked  as  in  aortic  regurgitation. 
Haimic  murmurs  and  slight  dilatation  of  the  left  ventricle 
are  almost  constant.  An  irregular  temperature  develops 
from  time  to  time — usually  iOO°  or  ioi°  F.,  more  rarely 
from  102°  to  104°  F.  At  other  times  the  temperature  may 
be  subnormal. 

The  urine  is  suggestive  of  the  disease ;  it  is  of  low 
specific  gravity  and  of  high  color,  and  it  contains  an  excess 
of  urobilin.  The  pigmentation  of  the  urine,  however,  is 
not  constant.  Gastro-intestinal  symptoms  of  anaemia  are 
common ;  diarrhoea,  however,  may  not  be  infrequent. 
Dropsical  swelling  of  the  ankles  attends  the  later  stages 
of  the  disease,  and  the  dropsy  may  become  general.  The 
tendency  to  hemorrhage  is  seen  in  purpuric  spots  and  in 
submucous  ecchymoses.  Retinal  hemorrhage  is  not  uncom- 
mon. Free  hemorrhages  from  mucous  surfaces,  with  the 
exception  of  epistaxis,  are  rather  infrequent. 

Prognosis. — The  course  of  the  disease  is  progressive, 
with  periods  of  temporary  improvement,  but  cases  of 
apparent  recovery  are  not  uncommon  since  the  inaugura- 
tion of  the  arsenic  treatment.  Death  is  usually  preceded 
by  a  prolonged  state  of  prostration,  stupor,  and  mild 
delirium  with  irregular  fever. 

Diagnosis. — According  to  Osier,  the  following  are  the 
essential  points  :  (i)  The  severe  grade  of  reduction  in  the 
number  of  the  red  cells ;  (2)  their  relative  richness  in 
hiemoglobin ;  (3)  the  presence  of  many  megalocytes  and 
gigantoblasts ;  (4)  the  absence  of  any  cause  for  secondary 
anaemia;  (5)  occasional  febrile  disturbances;  (6)  the  yellow 
tint  of  the  skin ;  (7)  hemorrhages,  particularly  retinal ;  (8) 
a  progressive  course  and  the  inefficiency  of  treatment. 


LK  UCOC  YTOSIS.  655 

Treatment. — Iron  in  pernicious  anaemia  seems  to  be 
worthless.  The  main  reliance  must  be  placed  on  arsenic 
in  full  doses,  given  to  the  point  of  tolerance.  Osier's  plan 
is  to  give  Fowler's  solution  in  3-minim  doses  after  meals, 
increased  to  5  minims  at  the  end  of  the  first  week,  to  10 
minims  at  the  end  of  the  second  week,  and  so  on  until  the 
patient  is  taking  20  or  25  minims  after  each  meal.  Toxic 
symptoms  are  rare.  Should  they  occur,  the  drug  is  to  be 
discontinued  until  the  poisoning  symptoms  cease,  and  is 
then  to  be  resumed  at  the  dose  at  which  the  patient  left 
off  In  some  cases  the  addition  of  phosphorus  seems  to 
be  beneficial.  Iron  may  be  given  if  arsenic  disagrees,  but 
not  much  is  to  be  expected  from  it.  Rest  in  bed  from  time 
to  time  is  important  in  conserving  the  patient's  strength. 
Prolonged  residence  in  a  warm  inland  climate  has  been 
recommended,  but  the  climatic  treatment  is  often  disap- 
pointing. The  diet  should  be  light  and  nutritious.  Mas- 
sage is  sometimes  found  to  be  beneficial. 

Delafield  describes  a  clinical  set  of  cases  midway  between 
simple  and  pernicious  anaemia,  occurring  in  those  past 
middle  life.  The  etiology  of  these  cases  is  obscure.  The 
blood  shows  the  changes  only  of  secondary  anaemia.  The 
symptoms  are  those  of  a  fairly  marked  anaemia,  but  im- 
provement under  treatment  reaches  only  to  a  certain  degree, 
and  the  patients  relapse  as  soon  as  treatment  is  discon- 
tinued. Absolute  recovery  does  not  occur.  In  this  class 
of  cases  arsenic  seems  to  be  of  no  use.  Iron  is  the  drug 
on  which  reliance  is  to  be  placed,  but  dietetic  and  hygienic 
treatment  seems  to  be  of  almost  equal  service. 

LBUCOCYTOSIS. 

By  the  term  "  leucocytosis  "  is  meant  a  temporary  increase 
in  the  number  of  the  white  blood-corpuscles  ;  this  is  a  con- 
dition entirely  distinct  from  the  disease  leukaemia.  Nor- 
mally the  ratio  of  white  to  red  corpuscles  is  i  :  500,  but  in 
leucocytosis  the  proportion  may  be  i  :  150  or  even  i  :  50. 

Physiological  leucocytosis  occurs  during  pregnancy  and 
after  hearty  eating. 

Inflaviniatory  leucocytosis  occurs  in  acute  infectious  dis- 


656       MAXLAL    OF  THE  PRACTICE    OF  MEDICINE. 

eases  attended  with  local  inflammaton-  reaction.  It  appears 
most  commonly  with  pneumonia,  diphtheria,  and  suppura- 
tive processes,  and  it  is  said  to  be  a  sign  of  good  prognostic 
value.- 

C^r/riV/'/irleucocytosis  occurs  in  the  cachexias  of  malignant 
tumors. 

Relative  leucocytosis  occurs  in  anaemia,  where,  from 
diminution  in  the  number  of  the  red  corpuscles,  the  white 
cells  appear  in  an  increased  ratio,  although  they  are  not 
actuall\-  increased  in   number. 

LEUKEMIA  (LEUCOCYTH^MIA). 

Etiology. — The  cause  of  the  disease  is  obscure.  There 
occur  acute  cases  which  suggest  bacterial  infection,  but 
upon  this  point  definite  knowledge  is  lacking.  In  about 
one-third  of  the  cases  there  is  the  history  of  malarial  poison- 
ing. Syphilis  seems  to  possess  some  obscure  relation  to 
the  disease.  Leukaemia  may  occur  at  any  age,  but  it  is 
most  common  in  middle  life.  Males  are  affected  twice  as 
frequently  as  females.  In  women  the  disease  often  appears 
at  the  time  of  the  climacteric  or  after  pregnancy. 

Pathology. — The  essential  lesions  are  found  in  the  blood, 
the  spleen,  the  lymphatic  glands,  and  the  bone-marrow. 
The  blood-changes  are  constant.  According  to  the  relative 
intensity  of  the  changes  in  the  other  structures  mentioned, 
splenic  (or  lienteric),  lymphatic,  and  myelogenous  forms  have 
been  described.  As  true  myelogenous  leukemia  is  so  very 
rare,  the  disease  is  usually  described  under  two  principal 
forms,  (i)  splenic-myelogenous  or  lieno-myelogenous,  and 
(2)  lymphatic  leukaemia. 

Blooei-cha?iges  consist  in  the  increased  number  of  white 
cells,  their  proportion  to  the  red  corpuscles  rising  to  i  :  20 
or  I  :  5,  or  the  cells  even  being  in  equal  proportions.  The 
increased  proportion  is  greater  in  the  splenic-myelogenous 
form  than  in  lymphatic  leukaemia.  The  blood  is  pale  and 
watery  and  may  be  whitish  or  brownish-red  in  color.  The 
red  cells  are  diminished,  but  not  to  an  excessive  degree; 
haemoglobin  is  reduced  to  a  somewhat  greater  proportion. 


LEUKyEMIA.  657 

Nucleated  red  cells  may  be  seen.      Charcot's    octahedral 
crystals  separate  when  blood-slides  are  kept  for  some  time. 

A  more   detailed  account  of  the   changes   of  the  white    cells    is   deemed 
advisable. 
•    In  the  normal  blood,  Ehrlich  describes  the  following  varieties  of  white  cells  : 

1.  Lyinphocytes,^\Vi'3\\,  equal  in  size  to  a  red  corpuscle.  The  nucleus  is  large, 
round,  stains  deeply,  and  is  surrounded  by  a  narrow  rim  of  non-granular 
protoplasm. 

2.  Large  ino7tomidear  leucocytes,  several  times  larger  than  the  red  cells. 
The  nucleus  is  oval  or  elliptical  and  is  surrounded  by  a  wide  margin  of  non- 
granular protoplasm. 

3.  A  transition  form  resembling  the  preceding,  but  the  nucleus  is  inden- 
tated. 

4.  Polymiclear  leucocytes,  smaller  than  the  large  mononuclear  forms,  with 
long,  twisted  nuclei  which  stain  deeply.  The  protoplasm  is  granular  and 
does  not  stain  easily.  To  these  cells,  owing  to  peculiarities  of  staining,  the 
name  "  neutrophiles  "  is  given. 

5.  Cells  like  the  preceding,  but  the  protoplasm  contains  coarse  granules 
which  stain  deeply  with  eosin,  hence  the  name  "  eosinophiles." 

In  normal  blood  these  varieties  of  white  cells  bear  a  fixed  proportion  to 
each  other — the  lymphocytes,  from  15  to  30  per  cent.,  the  polynuclear  leuco- 
cytes, from  65  to  80  per  cent.,  the  mononuclear  and  transitional  forms,  6  per 
cent.,  the  eosinophiles,  from  2  to  4  per  cent.  According  to  Osier,  the  charac- 
ter of  the  cells  in  splenic-myelogenous  leukaemia  differs  materially  from  that 
in  the  lymphatic  form. 

In  splenic-myelogenous  leukcemia  the  lymphocytes  are  rarely,  if  at  all,  in- 
creased;  the  eosinophiles  are  present  in  normal  or  increased  proportion,  so 
that  there  is  a  great  total  increase.  The  polynuclear  neutrophiles  are  usually 
relatively  diminished.  In  this  form  there  appears  a  new  variety  of  cell,  de- 
rived from  the  marrow  of  the  bones,  and  known  as  the  myelocyte.  These  cells 
are  large  and  contain  a  single  nucleus,  but  the  protoplasm  is  finely  granular  and 
does  not  stain  well  with  acid  coloring  matters,  resembling  in  this  regard  the 
neutrophiles. 

In  lymphatic  leukcemia  the  ratio  of  white  to  red  corpuscles  rarely  exceeds 
1 :  10.  The  increased  number  of  colorless  corpuscles  is  due  to  the  lympho- 
cytes, which  may  form  93  per  cent,  of  the  total  number  of  white  cells.  Eosin- 
ophiles and  red  nucleated  cells  are  rare,  and  myelocytes  do  not  occur. 

In  mixed  forms  of  leukaemia  the  blood-condition  may  deviate  from  either 
of  these  classical  types. 

The  accurate  study  of  stained  blood-specimens  is  highly  important  for  diag- 
nostic purposes  in  obscure  cases. 

The  spleen  is  usually  much  increased  in  size,  weighing 
from  two  to  eighteen  and  a  half  pounds.  The  enlargement  is 
due  to  a  true  hypertrophy  of  all  its  constituents.  In  acute 
cases   the  spleen  is  soft  and  inay  even  rupture.     In  pro- 

42 


658        MAXi'AL    OF   THE    PKACJ/CE    OF  MEDICIXE. 

tracted  cases  the  organ  becomes  firmer  and  the  capsule  is 
often  thickened  and  adherent  to  surrounding  structures. 
On  section  hemorrhages  ma)'  be  fountl  in  its  substance,  and 
there  may  be  seen  grayish-white  areas  which  consist  of 
aggregations  of  Ij'mphoid  cells. 

The  lesions  in  the  Iwnc-iiinrnnv  are  usualK'  associated  with 
the  splenic  enlargement.  A  pure  form  of  medullary  or 
myelogenous  leukaemia  is  exceedingly  rare.  The  marrow, 
which  is  yellowish  or  even  purulent  in  appearance,  contains 
many  lymphoid  and  nucleated  red  blood-cells. 

The  h'liip/iatic  g/aiids  may  be  involved  alone  (lymphatic 
leukaemia)  or  in  connection  with  the  splenic  and  medullary 
lesions.  The  histological  change  consists  of  hyperplasia  of 
the  glandular  tissue.  The  glands  are  enlarged  and  soft,  but 
are  freely  movable  and  do  not  mat  together.  In  many  cases 
the  glands  remain  perfectly  normal.  The  liver  is  usually 
increased  in  size,  from  a  diffuse  infiltration  of  Ij'mphoid  cells. 
New  growths  composed  of  lymphoid  cells  may  be  found  in 
various  parts  of  the  body,  especially  in  the  tonsils,  intestinal 
glands,  liver,  kidney,  retina,  lungs,  and  pleura.  The  hem- 
orrhagic tendency  of  the  disease  is  shown  by  hemorrhages 
in  various  parts  of  the  body,  especially  under  the  skin,  under 
the  serous  and  mucous  membranes,  and  in  the  retina. 

Symptoms. —  i.  There  are  regularly  present  anaemic 
symptoms  resembling  those  of  pernicious  anaemia,  so  that 
a  detailed  description  is  not  necessary.  Nervous  symptoms, 
however,  are  not  usually  marked.  CEdema  of  the  feet  and 
general  dropsy  are  commonly  present. 

2.  Hemorrhagic  symptoms  may  be  slight  or  may  lead  to 
a  fatal  issue.  Hemorrhages  may  occur  from  any  of  the 
mucous  surfaces  or  into  the  retina,  while  death  may  result 
from  cerebral  hemorrhages.  The  most  frequent  hemorrhages 
arise  from  the  nose,  stomach,  intestines,  lungs,  and  kidney. 

3.  There  may  be  an  irregular  fever  as  in  pernicious 
anaemia.  Rare  cases  of  acute  leukaemia  are  encountered, 
in  which  a  continuous  temperature  of  103°  or  104°  F.  is 
observed.  These  acute  cases  may  be  mistaken  for  typhoid 
fever  unless  blood-examination  be  made. 

4.  Splenic    tumor    is    readily    appreciated    by   palpation. 


leuk./[<:mia. 


I'l.A  IK  22. 


-/ 


Blood  stained  with  Ehrlich's  "triple  stain  "  of  acid  fuchsin,  methyl-green,  and  orange-G; 
drawn  with  the  camera  lucida  from  normal  hlood  (Osier,  in  American  Text-Book  of  the 
Theory  and  Practice  of  Medicine)  :  a,  red  corpuscles  ;  6,  lymphocytes  ;  r,  large  mono- 
nuclear leucocytes;  d,  transitional  forms;  e,  neutrophilic  leucocytes  with  polymorphous 
nuclei  fpolynuclear  neutrophiles)  ;/",  eosinophilic  leucocytes. 


LEUIOJ'.MIA.  659 

The  spleen  may  extend  to  or  beyond  the  umbilicus.  The 
free  edge  is  sharp  and  notched.  In  acute  cases  there  may  be 
pain  and  tenderness  over  the  spleen,  so  that,  in  connection 
with  its  enlargement,  abscess  of  the  organ  may  be  suggested. 
Rupture  of  the  spleen  in  acute  ca.ses  has  occurred.  In  pro- 
tracted cases  no  symptoms  are  caused  by  the  splenic  tumor 
except  those  due  to  its  increased  size  and  weight. 

5.  Changes  in  the  marrow  rarely  give  rise  to  clinical 
symptoms.  Exceptionally  there  is  pain  in  the  bones.  If 
the  sternum  be  affected,  it  may  be  tender  on  pressure. 

6.  Lymphatic  enlargements  do  not  occur  in  all  cases. 
More  rarely  the  lymph-glands  are  affected  alone,  with  the 
changes  in  the  blood ;  to  this  form  the  term  "  lymphatic 
leukaemia  "  has  been  given.  These  cases  usually  run  a  rapid 
course  with  fever  or  hemorrhages.  The  glands  enlarge,  but 
seldom  present  the  same  large  bunches  as  in  Hodgkin's  dis- 
ease. Pain  is  rare,  the  glands  usually  giving  rise  to  no 
symptoms  except  those  caused  by  pressure.  The  super- 
ficial glands  are  usually  first  involved,  next  in  frequency  the 
retroperitoneal  and  mesenteric  glands.  Enlargement  of 
the  abdominal  glands  may  often  be  appreciated  by  pal- 
pation. 

7.  Leukaemic  new  growths  may  be  discovered  in  the 
tonsils,  retina,  or  liver.  Leukaemic  deposits  in  the  liver 
may  give  the  symptoms  of  peritonitis. 

8.  In  males  persistent  priapism  may  occur ;  it  may  be  the 
first  symptom  of  the  disease. 

9.  The  urine  may  be  albuminous;  uric  acid  is  usually 
increased. 

The  diagnosis  is  to  be  made  upon  the  results  of  blood- 
examination.  Mild  degrees  of  leukaemia  may  be  differen- 
tiated from  excessive  leucocytosis  by  the  fact  that  in  the  latter 
the  polynuclear  neutrophils  are  alone  increased.  The 
diagnosis  from  Hodgkin's  disease  can  readily  be  made  by 
the  blood-examination. 

Prognosis. — The  course  of  the  disease  is  progressive,, 
although  through  appropriate  treatment  there  may  occur 
periods  of  temporary  improvement.  Acute  cases  terminate 
fatally  within  a  few  months ;  the  less  rapid  forms  terminate 


6CxD        M.l.VL'AL    OF   THE   PRACTICE    OF  MEDJCLXE. 

at  the  expiration  of  one  or  two  years.  Death  may  be  due 
to  anxmia,  exhaustion,  fatt\'  degeneration  of  the  heart,  or 
hemorrhage. 

The  treatment  is  practically  that  of  pernicious  anaemia. 
Iron  may  be  given,  but  any  great  amount  of  improvement 
from  its  use  is  not  to  be  expected.  Quinine  should  be 
given  to  malarial  cases,  and  potassium  iodide  and  mercury 
should  be  ordered  if  the  patient  be  syphilitic.  Arsenic  is 
the  drug  usually  employed,  and  its  use  is  frequently  fol- 
lowed by  brilliant  although  temporary  results ;  to  be  of 
service,  however,  the  drug  must  be  pushed  with  due  precau- 
tion vmtil  large  doses  are  reached.  During  treatment  by 
arsenic  the  number  of  the  white  cells  may  be  much  reduced. 

Splenic  remedies  have  been  tried,  but  they  are  not 
serviceable.  Faradism,  injections  of  ergotine  and  of  qui- 
nine, and  the  use  of  piperin  and  of  oil  of  eucalyptus  have 
been  recommended.  Extirpation  of  the  spleen  has  been 
performed,  with  a  mortality  of  95  per  cent.  Surgical  opera- 
tions are  extremely  dangerous  in  leukaemia,  owing  to  the 
liability  of  uncontrollable  hemorrhage. 

PSEUDO-LEUKEMIA. 

Etiology  and  Sjmonynis. — The  cause  of  pseudo-leu- 
kaemia is  obscure,  but  of  late  the  view  is  gaining  ground 
that  the  condition  is  an  infectious  process,  and  that  pseudo- 
leuktxmia  really  should  be  assigned  to  the  group  of  infec- 
tious tumors.  The  disease  is  more  frequent  in  males  than 
in  females,  in  the  proportion  of  3  :  i.  It  occurs  at  any  age, 
but  two-thirds  of  the  cases  are  observed  in  those  under 
fort}'  years.  In  some  cases  the  development  of  the  disease 
has  been  preceded  by  inflammatory  conditions  of  any  group 
of  lymphatic  glands.  Synonyms :  Hodgkin's  disease ; 
Lymphatic  anaemia;  Adenia;  General  lymphadenoma ; 
Pseudo-lcucoc)-thajmia ;    Malignant   lympho-sarcoma. 

Pathology. — The  lymphatic  glands  undergo  enlargement. 
Histologically  the  process  consists  of  an  increase  of  the 
lymphoid  cells,  with  or  without  increase  of  the  reticulum. 
At  first  the  glands  are  soft  and  elastic  ;  they  may  become 
firm  and  hard.       Isolated  and  freely  movable  at  first,  the 


PSE  UDO-L/C  UA'AiM/A.  66l 

glands  tend  finally  to  become  fused  together  to  form 
large  lobulated  tumors  surrounded  by  a  fibrous  capsule. 
The  new  growth  of  lymphatic  tissue  may  even  extend 
beyond  the  capsule  to  involve  neighboring  structures. 
Suppuration  of  the  superficial  glands  is  not  uncommon. 
The  glands  are  usually  affected  in  the  following  order  of 
frequency ;  the  cervical,  axillary,  inguinal,  mediastinal, 
retroperitoneal,  and    mesenteric   groups. 

The  spleen  is  enlarged  in  three-fourths  of  the  cases,  but 
the  increase  is  rarely  so  marked  as  in  leukaemia ;  in  one- 
half  the  cases  grayish-white  tumors  are  found  in  its  sub- 
stance ;  they  consist  of  lymphoid  cells  and  a  connective- 
tissue  reticulum.  The  lymphoid  cells  of  the  bone-marrow 
may  be  increased  in  number,  often  to  such  an  extent  that 
the  marrow  resembles  pus  in  its  appearance. 

Secondary  growths  of  lympJiatic  tissue  may  occur  in  any 
part  of  the  body,  especially  in  the  tonsils,  in  the  lymphoid 
tissue  at  the  base  of  the  tongue,  in  the  liver,  spleen,  kidneys, 
lungs,  pleura  (causing  fibrino-serous  effusion),  spinal  cord 
(causing  paraplegia),  and  in  the  skin.  The  ovaries,  testicles, 
and  dura  mater  may  also  be  the  seat  of  new  lymphatic 
growths. 

The  blood  shows  the  regular  changes  of  anaemia. 
Poikilocytes  and  nucleated  red  cells  are  not  present  to  any 
considerable  extent.  Lciicocytosis  does  not  normally  occur 
in  pseudo-leukaemia,  but  cases  occur,  occupying  a  middle 
ground  between  Hodgkin's  disease  and  lymphatic  leu- 
kaemia, in  which  the  white  cells  are  increased  in  number 
and  in  which  the  lesions  of  a  pure  lymphatic  leukaemia 
may  ultimately  develop.  Some  of  these  cases  occur  in 
children  under  two  years  of  age. 

Symptoms  are  due  (i)  to  anaemia,  (2)  to  the  enlargement 
of  the  lymphatic  glands,  and  (3)  to  the  secondary  lymphatic 
growths. 

I.  The  ancemia  gives  rise  to  the  regular  symptoms  of  that 
condition.  The  pallor,  hemorrhages,  oedema,  dyspnoea, 
and  the  cardiac  and  cerebral  symptoms  are  like  those  seen 
in  pernicious  anaemia,  and  need  not  be  again  described. 
Pigmentation    of  the    urine,   however,   does    not    occur   in 


66: 


M.iXr.lL    OF   TJIK    PRACTICE    OJ-    M EJ^JCIAE. 


Hodgkin's  disease.  The  anaemic  symptoms  may  precede 
or  follow  those  due  to  the  glandular  enlargements.  The 
temperature  is  usually  irregularly  elevated  even  during  the 
earlier  stages  of  the  disease.  The  fever  may  be  continuous 
or  recurrent.  Remarkable  ague-like  paroxysms  may  occur, 
separated  by  periods  of  normal  temperature.  The  duration 
of  the  febrile  paroxysms  ma}^  be  weeks  or  months. 


nJular  swellings  in  Hodgkin's  disease. 


2.  The  glaiuhilar  szuellings  are  frequently  the  first  symp- 
toms noticed.  The  glands  on  one  side  may  be  involved 
alone,  but  later  the  swellings  become  symmetrical.  At  first 
it  may  be  impossible  to  exclude  syphilitic  or  tubercular  dis- 
ease of  the  glands;  but  later,  when  large  bunched  tumors 
form,  the  diagnosis  is  usually  easy.      Marked  variations  in 


PSEUDO-LEUK'/KMIA.  663 

the  size  of  the  glands  may  be  observed  from  time  to  time. 
In  the  latter  stages  the  skin  may  be  involved  and  ulcerated. 
Enlarged  retroperitoneal  glands  may  reach  such  a  size  that 
large  abdominal  tumors  are  formed.  Besides  the  disfigure- 
ment caused  by  the  glandular  tumors,  important  symptoms 
may  arise  from  their  pressure  on  neighboring  structures. 
The  cervical  glands  may  press  upon  the  trachea  and  may 
necessitate  tracheotomy.  Enlargement  of  the  mediastinal 
glands  may  cause  pressure  upon  the  trachea,  oesophagus, 
bronchi,  vena  cava,  and  aorta.  Alarming  cardiac  disturbance 
may  arise  from  compression  of  the  vagus.  The  enlarge- 
ment of  the  abdominal  glands  may  cause  abdominal  pain ; 
they  may  press  upon  the  portal  vein  (causing  acites  and 
portal  obstruction)  or  upon  the  common  bile-duct  (causing 
persistent  obstructive  jaundice).  Pressure  upon  the  adrenals 
or  upon  the  splanchnic  nerves  may  be  followed  by  bronzing 
of  the  skin.  The  axillary  glands  may  press  upon  the 
brachial  or  axillary  veins  (causing  swelling  of  the  arm)  or 
upon  the  brachial  plexus  (causing  numbness,  tingling,  pain 
along  the  course  of  the  nerves,  or  paralysis).  The  enlarged 
glands  in  the  pelvic  and  iliac  regions  may  cause  sciatic  pain 
and  swelling  of  the  leg.  Lymphatic  growths  in  the  liver 
and  the  spleen  are  regularly  followed  by  an  increase  in  size 
of  these  organs. 

3.  New  lymphatic  growths  in  other  parts  are  followed  by 
the  regular  symptoms  of  small  tumors  in  the  affected  struc- 
tures. 

The  diagnosis  from  leukaemia  is  to  be  made  by  the 
blood-examination,  there  being  in  Hodgkin's  disease  no  in- 
crease in  the  number  of  the  white  cells.  The  occasional 
merging  of  pseudo-leukaemia  into  lymphatic  leukaemia 
should  not,  however,  be  forgotten.  The  diagnosis  from 
tubercular  adenitis  is  usually  rendered  easy  by  the  presence 
of  other  foci  of  tubercular  disease  in  the  latter  condition. 
Tubercular  adenitis  usually  involves  the  submaxillary  glands, 
whereas  in  Hodgkin's  disease  the  glands  along  the  borders 
of  the  sterno-mastoid  muscle  are  the  glands  first  to  be 
involved.  Suppuration  is  common  to  tubercular  glands, 
uncommon  to  those  of  Hodgkin's  disease. 


664        M.iXr.lL    OF   THE    Ph\lC77CJ:    (.>/■    MKDICIXE. 

Prognosis. — With  rare  exceptions  Hodgkin's  disease 
ultimately  ends  fatally.  The  course  of  the  disease  is  fre- 
.quently  marked,  however,  b\^  more  or  less  prolonged 
periods  of  improvement.  Acute  cases  may  run  a  course  of 
several  months  ;  the  more  protracted  cases  may  extend  over 
two  or  three  years.  Death  results  from  debility  and 
anaemia,  from  hemorrhage,  from  the  mechanical  pressure  of 
the  lymphatic  tumors,  or  from  intercurrent  disease. 

Treatment  is  mainly  that  of  pernicious  anaemia.  Arsenic 
is  to  be  given  until  the  point  of  tolerance  is  reached.  Phos- 
phorus has  also  been  recommended,  but  it  is  of  doubtful 
utility.  The  internal  use  of  Lugol's  solution  of  iodine  in 
from  5-  to  lo-drop  doses  after  meals  has  been  recommended. 
In  early  cases,  in  which  only  a  few  glands  are  enlarged, 
these  glands  may^  be  removed  by  surgical  operation.  Re- 
moval of  the  glands  may  also  be  resorted  to  in  case  of 
severe  pressure-symptoms. 

ADDISON'S  DISEASE. 

Etiology. — Addison's  disease  is  more  frequent  in  men 
than  in  women,  and  usually  occurs  in  middle  life,  although 
no  age  is  exempt.  About  the  causation  of  the  disease  there 
is  much  doubt.  Two  theories  exist:  (i)  That  the  disease 
is  due  to  loss  of  function  of  the  suprarenal  capsules. 
(2)  That  the  disease  is  due  to  irritation  of  the  abdominal 
sympathetic  plexus,  usually  owing  to  disease  of  the  nerves, 
the  ganglia,  or  the  adrenals.  In  other  cases  a  functional 
nerve-disturbance  must  be  supposed  to  exist. 

Pathology. — In  88  per  cent,  of  all  cases  the  adrenals  are 
found  diseased.  In  the  vast  majority  of  cases  the  lesion  in 
the  adrenals  is  tubercular,  the  capsules  being  converted  into 
masses  of  fibrous  tissue  and  cheesy  matter.  In  other 
cases  the  adrenals  are  found  atrophied,  absent,  or  the  seat 
of  malignant  tumors.  Against  the  theory  that  Addison's 
disease  is  due  to  loss  of  function  of  the  suprarenal  capsules 
through  disease  are  the  following  facts:  (i)  In  12  per  cent, 
of  all  cases  of  Addison's  disease  the  adrenals  are  found 
to  be  normal.  (2)  Every  variety  of  adrenal  lesion  has 
occurred  without  giving  rise  to  the  symptoms  of  Addison's 


ADJJ/SOjWS   JJfSJ'lAS/'..  66$ 

disease.  Owing  to  improved  technique  in  nerve-staining, 
there  are  found  an  increasing  number  of  cases  of  Addison's 
disease  in  which  lesions  are  found  in  the  sympathetic  nerve- 
structures  in  the  abdomen.  Of  the  30  cases  most  recently 
examined,  27  showed  sympathetic  nerve-lesions.  The 
ordinary  lesions  found  in  the  ganglia  and  nerve-fibres 
consist  of  degeneration,  congestion,  hemorrhages,  ^nd  in- 
filtration by  leucocytes  or  new  connective  tissue.  The 
blood  shows  the  changes  common  to  anaemia.  The  heart 
may  be  fatty ;  it  is  seldom  enlarged.  The  liver  shows  no 
essential  lesion.  The  spleen  may  be  somewhat  increased  in 
size.  Tubercular  changes  are  often  found  in  various  parts 
of  the  body  if  tubercular  disease  of  the  adrenals  be  present. 
Symptoms. — Four  cardinal  groups  of  symptoms  appear: 
(i)  prostration,  (2)  heart  weakness,  (3)  gastro-intestinal  symp- 
toms, and  (4)  bronzing  of  the  skin. 

1.  Prostration  is  shown  by  the  early  appearance  of  intense 
languor  both  of  body  and  of  mind.  The  patient  becomes 
weak,  dull,  apathetic,  listless,  and  peevish.  The  symptoms 
of  prostration  are  constant  and  progressive. 

2.  Heart  iveakness  is  attended  by  frequent  syncopal  at- 
tacks, any  one  of  which  may  be  fatal.  The  pulse  is  feeble 
and  rapid.  The  poor  condition  of  the  circulation  induces 
the  symptoms  of  cerebral  anaemia,  which  usually  are  well 
marked. 

3.  Gastro-intestinal  symptoms  diXQ:  almost  constant.  Nausea 
and  vomiting  may,  with  the  prostration,  appear  as  initial 
symptoms.  The  vomiting,  which  is  not  usually  influenced 
by  diet,  cannot  be  accounted  for  by  any  lesion  found  in  the 
stomach,  but  seems  to  be  of  nervous  origin.  The  vomiting 
occurs  in  violent  paroxysms  and  becomes  more  distressing 
as  the  disease  progresses.  Diarrhoea  is  twice  as  frequently 
observed  as  constipation. 

4.  The  bronzing  of  the  skin  is  usually  observed  after  the 
constitutional  symptoms  have  lasted  for  some  little  time. 
In  other  cases  it  is  the  first  symptom  observed.  The  pig- 
mentation of  the  skin  usually  begins  in  the  exposed  portions 
of  the  body,  as  the  face  and  the  hands,  or  in  areas  exposed 
to  friction  of  the  clothing,  or  in  places  which  are  normally 


666        M.lXr.lL    OF  THE    PRACTICE    OF  MEDICIXE. 

pigmented,  as  about  the  nipples.  The  color  varies  from  a 
yellow  to  a  brown  or  even  a  black.  The  pigmentation  may 
at  first  occur  in  scattered  areas,  but  finally  tends  to  become 
diffused,  so  that  the  patient  may  resemble  a  mulatto.  Simi- 
lar discoloration  may  be  found  in  the  mucous  membrane  of 
the  lips,  gums,  and  tongue.  Internal  pigmentation  does  not 
usually  occur. 

Among  the  remaining  symptoms  to  be  enumerated,  the  most 
important  are  pain  and  tenderness  in  the  lumbar  or  epigas- 
tric regions  ;  these  symptoms  occur  in  one-third  of  the  cases. 
In  the  last  stages  of  the  disease  the  patients  become  ex- 
tremely feeble  and  may  develop  stupor,  delirium,  coma, 
or  general  convulsions.  Death  occurs  from  asthenia  or 
from  syncope.  In  a  few  acute  cases  the  disease  runs  a 
course  with  fever,  vomiting,  diarrhoea,  and  intense  exhaus- 
tion, and  before  the  pigmentation  appears  the  diagnosis  may 
be  impossible. 

Prognosis. — Recovery  is  practically  unknown.  Acute 
cases  may  terminate  within  a  few  months.  The  average 
duration  is  about  one  year,  but  cases  are  on  record  in  which 
the  symptoms  continued  as  long  as  ten  years. 

Treatment  is  sj-niptomatic,  as  for  the  disease  itself  no 
curative  treatment  is  known.  The  patient  should  be  guarded 
from  causes  leading  to  syncope,  and  anremic  conditions 
should  be  controlled  by  iron  and  arsenic.  The  vomiting 
may  be  alleviated  by  bismuth,  creosote,  hydrocyanic  acid, 
or  codeia.  Purgatives  should  be  given  with  caution,  as  they 
may  induce  an  exhausting  diarrhcea. 

TUBERCULOSIS   OF   THE    LYMPH-GLANDS 

(SCROFULA). 

Etiology. — Scrofula  is  tubercle,  and  the  etiology  of 
scrofula  is  therefore  that  of  other  tubercular  infections. 
Tubercular  infection  of  lymphatic  glands  is  favored  by 
previous  adenitis,  so  that  children  with  catarrhal  inflamma- 
tions of  the  mucous  mcinbranes  that  excite  adenitis  of  the 
*  neighboring  lymphatic  glands  seem  to  be  especially  sub- 
ject to  subsequent  lymphatic  tuberculosis. 

The    pathology  of    scrofula    is    that  of  tubercular  foci. 


TUBERCULOSIS   OF   THE   LYMPH-GLANDS.  667 

which  are  usually  localized  in  certain  groups  of  glands 
and  show  a  tendency  to  spontaneous  healing.  In  many 
cases  suppuration  of  the  infected  glands  occurs,  espe- 
cially with  tubercular  glands  in  the  neck.  In  these  in- 
stances the  pus  is  usually  sterile,  and  it  is  not  known 
whether  the  suppuration  is  excited  by  the  tubercle  bacilli 
and  their  products  or  by  a  mixed  infection  of  pus-or- 
ganisms. An  unhealed  focus  of  tubercular  adenitis  may 
at  any  time  discharge  bacilli  into  the  blood-vessels  or  the 
lymph-vessels  ;  it  is  said  that  three-quarters  of  the  cases 
of  acute  miliary  tuberculosis  originate  in  this  way. 

Symptoms. — i.  Gene^ml  tuberculous  lymphadenitis  is  a 
rare  condition,  and  usually  occurs  in  the  negro  race.  The 
lymph-glands  throughout  the  body  are  the  seat  of  a  diffuse 
tubercular  infiltration.  Acute  cases  resemble  clinically 
Hodgkin's  disease,  but  there  is  apt  to  be  more  fever. 

2.  Local  Tuberculous  Lymphadenitis. — {a)  Cervical. — This 
form  is  frequently  seen,  especially  in  tenement-house  and 
asylum  children  and  in  the  negro  race.  The  submaxillary 
glands  are  usually  the  first  to  be  involved,  and  subsequently 
the  cervical  chains  of  glands  become  infected.  The  glands 
may  remain  isolated  and  mobile,  but  they  tend  to  become 
fused  so  as  to  form  large  knobby  tumors.  Suppuration  is 
common.  For  the  details  of  this  affection  the  reader  is 
referred  to  works  on  surgery. 

{b^  Bronchial. — The  bronchial  glands  are  extremely  sub- 
ject to  infection,  and  they  may  be  involved  with  or  without 
local  lesions  in  the  lung.  Acute  miliary  tuberculosis  is  apt 
to  result.  (For  details  see  Miliary  Tuberculosis  and  Bron- 
cho-pneumonia.) 

(c)  Mesenteric  {Tabes  Mesenterica). — In  this  form  the 
mesenteric  and  retroperitoneal  glands  are  enlarged  and 
tubercular.  They  may  suppurate,  or  they  may  become 
encapsulated  and  infiltrated  by  lime-salts.  Mesenteric 
tuberculosis  may  be  primary  or  may  complicate  tubercular 
disease  of  the  intestines. 

The  treatment  of  tubercular  adenitis  is  that  of  tuber- 
culosis in  general.  Cervical  tubercular  glands  may  be 
removed. 


Vm.  DISEASES  OF  THE  NERVOUS 
SYSTEM. 


J,    DISEASES  OF  THE  MEMBRANES  OF  THE 
BRAIN. 

ia)   Diseases  of  the  Dura  Mater. 

ACUTE  EXTERNAL  PACHYMENINGITIS. 

Etiolog-y. — Pach\-nieningitis  is  regularly  secondary  to 
injuries  and  diseases  of  the  cranial  bones  and  to  suppura- 
tive disease  of  the  middle  ear  and  of  the  mastoid  cells. 

Pathology. — The  dura  is  thickened  by  a  purulent  infil- 
trate ;  the  products  of  inflammation  collect  between  the 
dura  and  the  skull,  forming  a  circumscribed  abscess.  The 
lesion  is  usually  localized  over  one  cortex.  The  inflamma- 
tion may  extend  to  the  pia  mater  or  to  the  venous  sinuses. 

The  symptoms  are  usually  obscure.  Pain  is  usually 
referred  to  the  seat  of  the  lesion.  Septic  symptoms  develop, 
and  compression-symptoms  may  result  in  hemiplegia  if  the 
motor  area  be  pressed  upon. 

The  prognosis  is  good  if  the  treatment  be  scientific  and 
if  the  pia  and  the  venous  sinuses  be  not  invoked. 

The  treatment  consists  in  trephining  and  draining  the 
abscess-cavit\\ 

ACUTE  INTERNAL  PACHYMENINGITIS. 

Etiology. — Pach\-meningitis  interna  is  secondary  to  in- 
flammation of  the  external  surface  of  the  dura,  or  compli- 
cates erysipelas,  Bright's  disease,  pyaemia,  pneumonia,  puer- 
peral fever,  and  the  exanthemata. 

Pathology. — The  inner  surface  of  the  dura  is  covered 
with  fibrin  and  pus  or  with  pus  alone ;  the  thickness  of  the 
dura  is  not  usually  involved.     The  inflammation  is  apt  to 

fifiS 


C'lIRONIC  INTERNAL    PACHYMENINGIT/S.  669 

extend  to  the  pia  and  to  the  venous  sinuses.  The  purulent 
exudation  is  usually  circumscribed  over  the  cortex. 

The  symptoms  resemble  those  of  a  localized  purulent 
meningitis.  In  the  complicating  cases  the  symptoms  may 
be  so  obscured  by  those  of  the  primary  disease  that  the 
diagnosis  is  rendered  obscure. 

The  prognosis  is  not  good,  owing  to  the  liability  to 
meningitis  and  thrombosis  of  the  cerebral  sinuses. 

The  treatment  is  that  of  meningitis. 

CHRONIC  INTERNAL  PACHYMENINGITIS. 

Etiology  and  Synonyms. — The  disease  is  usually  found 
in  males  over  fifty  years  of  age ;  it  occurs  in  connection 
with  insanity  and  degenerative  diseases  of  the  brain.  Al- 
most all  the  subjects  are  markedly  alcoholic,  and  the  disease 
is  one  almost  exclusively  of  tramps  and  almshouse  inmates. 
Synonyms :  Hemorrhagic  pachymeningitis;  Haematoma  of 
the  dura  mater. 

Pathology. — The  disease  is  characterized  by  the  growth 
of  a  new  membrane  upon  the  dura,  usually  involving  a  small 
area  over  one  cortex.  In  the  earlier  stages  this  membrane 
resembles  a  brownish-red  staining  of  the  dura,  and  consists 
of  large,  thin-walled  blood-vessels  supported  by  a  delicate 
connective-tissue  framework.  From  these  blood-vessels 
hemorrhages  occur,  constituting  the  principal  feature  of  the 
disease.  In  the  later  stages  the  dura  is  thickened  over  the 
affected  area  by  dense  fibrillated  connective  tissue,  and  upon 
its  inner  surface  the  original  membrane  is  found  as  already 
described.  The  dura  may  be  from  half  an  inch  to  an  inch 
thick,  and  thus  the  brain  becomes  slowh'  compressed ; 
the  compression  of  the  brain  is  further  increased  by  hemor- 
rhage between  the  dura  and  the  pia,  which  may  occur  at  any 
time. 

The  symptoms  are  due  to  slow  and  to  sudden  brain- 
compression. 

Slow  Coinpressio7i. — Headache  is  prominent,  constant,  and 
usually  localized.  There  are  loss  of  memory  and  increasing 
stupidity.  The  gait  is  shambling,  slow,  and  unsteady,  but 
paralysis  and  ataxia  are  not  observed.    The  speech  becomes 


6/0        MAXr.lL    OF   THE   PRACTICE    OF  MEDICIXE. 

slow,  faltering,  and  scanning.  One  or  both  pupils  may  be 
contracted.  In  the  earlier  stages  of  the  disease  these  symp- 
toms are  not  marked. 

Snddoi  conipnssiini  is  caused  by  meningeal  hemorrhages. 
The  patient  will  become  unconscious,  with  or  without  pre- 
ceding convulsions,  and  will  develop  hemiplegia  (see  Menin- 
geal Hemorrhage).  The  hemorrhage  may  occur  sponta- 
neously or  after  exertion,  or  after  a  blow  or  an  injury  to  the 
head.  In  the  latter  instance  the  disease  possesses  great 
medico-legal  interest.  The  hemorrhage  may  occur  early 
in  the  disease  and  may  be  the  initial  symptom. 

Prognosis. — The  disease  is  slow  in  its  progress,  extend- 
ing over  years.  Rare  cases  of  recovery  have  been  reported. 
Death  usually  occurs  from  degeneration  of  the  brain  with 
insanity,  or  from  hemorrhage. 

Treatment. — As  the  diagnosis  from  syphilitic  meningitis 
cannot  in  all  cases  be  made,  potassium  iodide  should  be 
given  in  full  doses.  This  treatment,  however,  is  of  no  ser- 
vice in  non-syphilitic  pachymeningitis.  The  treatment  of 
the  disease  is  chiefly  prophylactic.  Quiet,  easy  employ- 
ment, and  the  avoidance  of  severe  bodily  exertion  should 
be  enforced,  to  lessen  the  chance  of  meningeal  hemorrhage. 

SYPHILITIC  PACHYMENINGITIS. 

This  disease  will  be  considered  under  the  heading  of 
Syphilitic   Disease  of  the   Brain-membranes. 

{6)  Diseases  of  the  Pia  Mater. 
The  pia  mater  may  be  the  seat  of  a  tubercular,  a  non- 
tubercular,  and  a  syphilitic  inflammation.     Its  inflammations 
are  called  "  meningitis  "  or  "  leptomeningitis." 

TUBERCULAR  MENINGITIS. 

Etiology. — In  young  children  tubercular  meningitis  is 
regularly  only  part  of  an  acute  general  tuberculosis.  For 
the  etiology  see  the  latter  disease. 

In  adults  tubercular  meningitis  is  usually  a  local  inflam- 
mation secondary  to  some  pre-existing  tubercular  dis- 
ease.     In    some    adults    with    acute    general    tuberculosis 


TUBERCULAR  MENINGfT/S.  6/1 

the  lesions  of  tubercular  meningitis  may  be  found  at  the 
autopsy,  but  clinical  symptoms  during  life  are  not  usually 
observed  in  these  cases. 

Tubercular  meningitis  is  most  common  in  children  be- 
tween two  and  seven  years  of  age.  In  adults  the  disease  is 
rare  after  the  twenty-fifth  year.  The  attack  may  seem  to 
be  induced  by  some  exciting  cause,  as  a  blow,  a  fall,  or 
exposure  to  a  hot  sun. 

Pathology. — Upon  removing  the  skull-cap  the  brain 
appears  too  large  and  the  convolutions  are  flattened.  The 
tubercles  appear  as  small  grayish  points,  occasionally  with 
cheesy  centres.  The  tubercles  are  most  abundantly  found 
along  the  course  of  the  blood-vessels  and  in  the  sulci.  They 
may  be  confined  to  the  base  (hence  the  name  "  basilar  men- 
ingitis ")  or  they  may  be  more  uniformly  distributed.  The 
pia  about  the  tubercles  is  thickened  by  serum  and  by  cel- 
lular infiltration.  Properly  speaking,  there  should  be  no 
purulent  exudate,  but  a  fibrino-purulent  exudate  is  not 
uncommon  from  a  "  mixed  infection."  The  cortex  is 
oedematous  and  is  infiltrated  with  cells.  In  children  the 
ventricles  are  regularly  distended  with  clear  or  turbid  serum, 
and  the  walls  of  the  ventricles  are  studded  with  tubercles 
("  acute  hydrocephalus  ").  This  distention  may  be  so  great 
that  the  septum  between  the  lateral  ventricles  will  rupture, 
and  great  compression  of  the  brain  from  within  outward  will 
ensue.  In  adults  the  distention  of  the  ventricles  is  less  fre- 
quent. In  all  cases  tubercular  inflammations  are  seen  in 
other  parts  of  the  body. 

The  symptoms  may  be  classically  divided  into  four 
groups : 

Prodromal  Symptoms. — The  child  is  irritable,  restless,  and 
disinclined  to  play.  Causeless  vomiting  is  a  symptom  which 
in  children  is  suggestive  of  incipient  meningeal  inflammation. 

Symptoms  of  Brain-irritation. — The  child  may  be  taken 
with  convulsions  or  a  chill.  Fever  develops  and  runs  an 
irregular  course.  The  temperature  may  vary  between  iOO° 
and  103°  F.  with  irregular  remissions;  more  rarely  a  fever 
of  104°  to  105°  F.  is  encountered.  The  temperature  gives 
no  euide  to  the  diagnosis,  nor  does  it   indicate  the  actual 


6/2        J/.-LVr.l/.    OF   THE   J'K.tCT/CE    OF  .yF.D/C/\F.. 

scv'crity  of  the  disease.  Headache  becomes  severe,  and  the 
special  senses  are  so  h\per;vsthetic  that  the  child  becomes 
intolerant  of  liy^ht  or  noise,  and  tlic  hyperaesthesia  of  the 
skin  may  render  any  handling;  of  the  patient  extremely  pain- 
ful. There  is  rigiditj'  and  retraction  of  the  back  of  the  neck  ; 
the  muscles  generally  are  rigid  and  resist  passive  motion, 
and  the  general  attitude  is  one  of  general  flexion  which  is 
quite  characteristic.  Convulsive  movements  or  automatic 
motions  are  common.  Mild  or  violent  delirium  develops, 
alternating  with  periods  of  stupor  in  which  the  child  may 
moan  or  give  vent  to  the  shrill  "  hydrocephalic  cry."  The 
pupils  are  usually  contracted.  The  pulse  varies  between 
1 10  and  1 20.  Vomiting  attacks  occur  without  nausea,  and 
are  not  influenced  b)'  the  taking  of  food.  The  bowels  are 
usually  obstinately  constipated.  The  abdomen  is  retracted 
and  "  boat-shaped." 

Symptoms  of  braiii-comprcssion  next  appear,  and  are  due 
not  only  to  the  thickening  of  the  pia,  but  also  to  the  disten- 
tion of  the  ventricles.  The  child  becomes  dull  and  apathetic. 
The  special  senses  are  blunted.  Stupor  succeeds  the  delirium 
and  merges  into  coma.  The  automatic  motions  of  the  hands 
and  feet  may  continue,  or  there  may  be  evident  paralysis  of 
certain  groups  of  muscles,  of  which  paralyses  squint  is  the 
most  easih'  recognized.  The  pulse  may  now  become  slowed 
to  90,  80,  or  even  ^o  in  the  minute.  This  characteristic 
slowness  of  the  pulse,  however,  may  not  be  marked  in  }'oung 
children.  Irregularity  of  the  pulse  is  frequently  observed. 
The  coma  becomes  profound,  the  sphincters  relax,  paralysis 
becomes  more  evident;  the  pulse  during  the  last  stages  of 
the  disease  becomes  rapid  and  feeble,  and  the  breathing 
becomes  irregular  and  may  assume  the  Cheyne-Stokes 
variety.  Death  occurs  from  depression  of  all  the  vital 
functions. 

Not  all  cases,  however,  run  this  classical  course.  The 
symptoms  of  irritation  and  of  compression  may  be  vari- 
ously admixed,  according  to  the  intensity  of  the  inflam- 
mation in  various  portions  of  the  pia  mater.  Some  young 
children  are  seized  at  the  onset  with  convulsions,  which  may 
be  repeated;  the  child  becomes  stupid  and  drow.sy,  moans  as 


ACUTE   NO N- TUBERCULAR   MKNINGfTIS.  673 

if  in  pain,  and  develops  irregular  fever  ;  the  rhythm  of  the 
respirations  becomes  disturbed,  and  coma  precedes  a  fatal 
issue.  In  adults,  owing  to  the  less  frequent  movement  of 
the  ventricles,  the  compression-symptoms  are  less  marked. 

The  prognosis  is  uniformly  bad. 

The  duration  of  the  disease  is  from  one  to  four  weeks. 

The  treatment  is  that  of  acute  non-tubercular  meningitis. 

ACUTE  NON-TUBERCULAR  MENINGITIS. 

Etiology. — Meningitis  is  regularly  due  to  germ-infection 
of  the  pia  mater.  The  inflammation  of  the  pia  mater  occurs 
as  the  characteristic  lesion  of  epidemic  cerebro-spinal  menin- 
gitis. 

Cases  of  secondary  pus-infection  occur  more  commonly, 
the  germs  infecting  the  meninges  (i)  by  direct  extension  or 
(2)  through  the  arteries. 

1.  By  direct  extension,  following  inflammation  or  injury  of 
the  bones  of  the  skull,  of  the  dura  mater,  or  of  the  orbital 
cavity.  The  most  frequent  cause  is  necrosis  of  the  petrous 
portion  of  the  temporal  bone  from  middle-ear  disease.  The 
germs  may  travel  along  the  nerve-roots  during  the  course 
of  facial  erysipelas,  or  a  phlebitis  arising  from  suppuration 
of  the  orbit  or  cheek  may  infect  the  cavernous  sinus  and 
thus  spread  to  the  pia. 

2.  Tlirough  the  Arteries. — Infectious  emboli  may  occur  in 
the  course  of  pyaemia,  abscess  of  the  lung,  and  malignant  en- 
docarditis. Bacterial  infection  also  occurs  during  the  course 
of  certain  infectious  diseases,  especially  pneumonia,  ery- 
sipelas, typhoid  fever,  rheumatism,  and  the  exanthemata. 
Infection  is  favored  b)'  Bright's  disease  and  gout.  The  con- 
gestion following  sunstroke  predisposes  to  meningitis. 

Pathology. — Two  anatomical  forms  are  found,  w^hich 
during  life  give  rise  to  the  same  clinical  symptoms  : 

1.  Cellular  Meningitis. — The  pia  is  congested,  dry,  and  lus- 
treless. The  substance  of  the  pia  is  the  seat  of  a  cellular 
infiltration.  There  is  no  purulent  exudate.  This  form  is 
analogous  to  the  cellular  form  of  peritonitis  in  peritoneal 
septicaemia. 

2.  Exudative  Meningitis. — There  is  an  exudation  of  fibrin, 

43 


6;4      .y.i.vL'.iL  OF  riiK  practice  of  medicine. 

serum,  and  pus  into  the  thickness  of  the  pia,  more  rarcl\- 
appearing  upon  its  free  surface.  In  children  and  in  young 
adults  the  lining  of  the  ventricles  becomes  inflamed  and  the 
\'entricles  become  distended  with  turbid  serum.  The  pia 
mater  covering  the  spinal  cord  may  be  involved  by  direct 
extension.  The  locality  of  the  meningitis  varies.  In 
pneumonia  and  in  malignant  endocarditis  the  process  is 
usually  bilateral  and  limited  to  the  cortex  ;  with  middle-ear 
disease  the  lesion  is  over  the  temporo-sphenoidal  lobe  on 
one  side  ;  in  other  cases  the  base  alone  may  be  involved. 
In  children,  should  the  patient  recover  from  the  meningitis, 
the  ventricles  ma)-  remain  distended  for  some  time. 

The  symptoms  depend  largeh-  upon  the  character  of  the 
original  disease. 

1.  If  the  meningitis  follow  middle-ear  disease,  the  symp- 
toms of  meningitis  are  well  developed  and  resemble  those 
of  the  tubercular  or  the  epidemic  form,  so  that  a  further 
description  is  unnecessary.  The  diagnosis  from  tubercular 
meningitis  is  to  be  made  by  attention  to  the  following 
points : 

Tubercular  RIeningitis.  Simple  Meningitis. 

History  of  tuberculosis.  History  of  ear  disease,  etc. 

No  apparent  cause.  Cause  evident. 

Longer  prodromal  period.  Short  prodromal  period. 

Longer  course.  Short  course. 

Presence  of  tuberculosis  in  No  tuberculosis. 

the  lungs,  etc. 

Heredity  in  20  per  cent.  No  heredity. 

2.  If  the  meningitis  complicate  severe  infectious  disease, 
the  symptoms  may  be  obscured  by  those  of  the  original 
disease.  Retraction  of  the  head  and  paralyses  may  consti- 
tute the  only  suggestive  symptoms.  Facial  paralysis  and 
squint  are  usually  the  most  evident.  The  pulse  may  or 
may  not  become  slower,  but  it  usually  becomes  irregular. 
Irregularities  of  the  rhythm  of  respiration  are  usually 
observed.  It  may  be  impossible  to  differentiate  between 
pnuemonia  in  children  with  cerebral  symptoms  and  pneu- 
monia complicated  by  meningitis. 

The  duration  is  about  a  week,  but  the  disease  may  con- 
tinue for  from  two  to  four  weeks. 


CI  IRONIC  MICNINGITIS.  6y$ 

The  prognosis  is  bad,  yet  a  number  of  patients  recover. 

Treatment. — Tlie  patient  should  be  kept  free  from  noise 
and  hght.  The  continual  use  of  the  ice-cap  throughout 
the  disease  is  frequently  of  service,  and  should  always  be 
employed.  Leeches  should  be  applied  behind  the  ear  in 
robust  cases,  but  depletion  in  the  latter  stages  of  the  disease 
is  not  to  be  advised.  Blisters  to  the  occiput  add  to  the  dis- 
comfort of  the  patient  and  do  no  good.  Calomel  and  mag- 
nesium sulphate  should  be  given  at  the  outset,  in  such 
doses  as  will  act  on  the  bowels  and  reduce  the  meningeal 
congestion.  Ergot  is  advised  during  the  earlier  stages,  to 
reduce  congestion.  Potassium  iodide  in  5-  to  lO-grain  doses 
is  employed  as  a  routine  treatment,  but  its  use  is  theoretical. 
The  restlessness  and  headache  are  to  be  controlled  by 
opium,  phenacetine,  chloral,  bromide  of  sodium,  and  sul- 
phonal.  For  the  tubercular  form  the  head  may  be  shaved 
and  covered  with  iodoform  ointment;  for  this  treatment 
good  results  have  been  claimed.  Should  menmgitis  follow 
middle-ear  disease  or  suppurative  disease  of  the  dura,  local- 
ized trephining  and  drainage  should  be  practised. 

To  avoid  meningitis  prophylactic  treatment  should  be 
directed  toward  the  careful  cleansing  of  the  ear  in  suppura- 
tive otitis  media,  the  opening  and  draining  of  abscesses  of 
the  mastoid  cells,  and  the  antiseptic  treatment  of  suppura- 
tive processes  about  the  cheeks  and  the  orbit. 

SYPHILITIC  MENINGITIS. 

(See  Syphilis  of  the  Brain.) 

CHRONIC  MENINGITIS. 
Etiology  and  Synonym. — The  disease  is  one  of  middle 
life,  and  is  most  commonly  seen  in  those  who  have  led  a 
life  of  privation  and  exposure.  It  is  common  in  tramps  and 
in  the  inhabitants  of  almshouses.  Chronic  alcoholism  and 
cerebral  endarteritis  seem  to  lead  to  the  disease.  Chronic 
meningitis  may  complicate  fractures  or  inflammation  of  the 
cranial  bones,  chronic  pachymeningitis,  chronic  Bright's 
disease,  chronic  degenerations  of  the  brain,  and  slow-srow- 
ing  cerebral  tumors.     Synonym  :  Chronic  leptomeningitis. 


6/6     j/.Lvr.iL  OF  THE  practice  of  medicine. 

Pathology. — The  pia  mater  is  thickened,  opaque,  oedem- 
atous,  and  infiltrated  with  cells.  There  may  be  adhesions 
between  the  pia  and  the  dura.  The  brain-cortex  may  be 
softened  or  sclerotic.  The  ventricles  may  be  distended  with 
clear  serum,  and  the  ependyma  lining  them  may  be  thick- 
ened and  rough.  The  meningitis  may  be  localized  at  the 
base  or  the  cortex  of  the  bram. 

The  symptoms  are  those  of  slow  compression  ;  they  re- 
semble those  of  chronic  pachymeningitis  except  that  hemor- 
rhages do  not  occur. 

Prognosis. — The  disease  is  chronic  in  its  course,  extend- 
ing over  }'ears,  but  recovery  cannot  be  expected. 

Treatment. — Syphilitic  meningitis  should  be  excluded 
b)'  a  conscientious  trial  of  mercury  and  of  potassium  iodide 
in  full  doses.     Otherwise  the  treatment  is  symptomatic. 

MENINGEAL  HEMORRHAGE. 

Hemorrhage  may  occur  between  the  dura  mater  and  the 
bones  of  the  skull,  and  between  the  dura  and  the  pia  mater. 

Hemorrhage  between  the  Dura  Mater  and  the 
Boxes  of  the  Skull. — Etiology. — These  hemorrhages  are 
regularly  due  to  violence,  either  by  concussion  separating 
the  dura  from  the  cranial  bones  and  laceratmg  the  middle 
meningeal  artery,  or  by  fracture  of  the  cranial  vault. 

The  sym.ptoms  are  those  of  shock,  laceration  and  com- 
pression of  the  brain,  followed  by  the  symptoms  of  menin- 
gitis. Although  these  cases  are  of  surgical  rather  than  of 
medical  interest,  they  are  important  to  the  physician,  owing  to 
the  unpleasant  results  that  follow  an  erroneous  diagnosis.  A 
man  whose  breath  is  alcoholic  may  be  found  unconscious  in 
the  street  with  a  scalp-wound.  The  case  is  regarded  as 
one  of  alcoholism,  but  the  coma  deepens,  the  temperature 
rises,  and  the  patient  dies.  At  the  autopsy  there  is  found  a 
fracture  of  the  skull  with  laceration  of  the  middle  cerebral 
artery  and  meningeal  hemorrhage. 

Treatment. — In  suspected  cases  incision  should  be  made, 
exposing  the  site  of  probable  fracture.  When  the  diagnosis 
is  made,  trephining  and  removal  of  the  clots  should  at  once 
be  resorted  to. 


meningeal  jiemor kj/agk.  677 

Hemorrhage  between  the  Dura  Mater  and  the  Pia 
Mater. — Etiology. — This  form  of  meningeal  hemorrhage 
may  occur  from — (i)  Traumatism  ;  (2)  thrombosis  of  the 
venous  sinuses ;  (3)  in  new-born  children  as  the  result  of 
severe  labor  or  the  pressure  of  forceps ;  (4)  chronic  hemor- 
rhagic pachymeningitis  ;  (5)  rupture  of  an  aneurysm  of  one 
of  the  cerebral  arteries;  (6j  after  convulsions  in  children; 
(7)  hemorrhagic  diseases.  The  disease  may  occur  at  all 
ages,  thus  differing  from  cerebral  hemorrhage. 

Pathology, — The  hemorrhage  may  be  at  the  base  of  the 
brain,  at  the  convexity,  or  may  be  more  equally  distributed. 
Small  hemorrhages  may  ultimately  be  absorbed,  leaving 
haematin  staining.  It  must  be  remembered  that  in  cerebral 
hemorrhage  the  blood  may  rupture  through  the  cortex  or 
may  leak  out  by  the  fourth  ventricle  and  appear  between 
the  membranes. 

The  symptoms  vary  according  to  the  size,  location,  and 
cause  of  the  hemorrhage. 

1.  Lai^ge  Clot  over  One  Cortex. — There  is  sudden  coma, 
with  stertorous  breathing,  slow  pulse,  and  abolition  of  all 
reflexes.  There  may  be  hemiplegia  or  monoplegia,  according 
to  the  size  and  position  of  the  hemorrhage.  Convulsive 
movements  of  muscles  ultimately  to  be  paralyzed  may  occur. 
The  temperature  falls  to  96°  or  97°  F".,  but  subsequently 
rises  to  103°  or  105°  F.  or  even  higher.  The  patient  may 
die  in  coma  within  twenty-four  hours,  or  may  die  in  several 
days  with  the  symptoms  of  meningitis.  Recovery  occurs 
only  if  the  clot  be  small.  Small  hemorrhages  over  a  con- 
vexity may  give  rise  to  the  symptoms  of  acute  meningitis 
without  the  occurrence  of  sudden  coma. 

2.  Clots  over  both  heniisplieres  give  rise  to  sudden  coma 
and  general  convulsions,  so  that  the  diagnosis  from  uraemia 
may  be  one  of  great  difficulty. 

3.  Hejiiorrhagc  at  the  base  of  the  brain  compresses  the 
medulla  and  leads  to  death  in  a  few  hours.  A  high  ante- 
mortem  temperature  is  usually  observed  in  these  cases. 

4.  Meningeal  Hemorrhage  of  the  New-born. — The  child 
maybe  stillborn,  or  it  may  be  born  in  asphyxia,  from  which 
it  may  die,  or  from  which  it  may  recover,  only  to   die   in 


6/8        A/AXCAL    OF   THE   PA'ACT/CK    OF  MEDICIXE, 

coma  with  convulsions  witliin  a  few  days.  In  those  who 
hve,  symptoms  of  parahsis  with  or  without  athetosis,  mental 
defects,  and  epileptic  seizures  max*  develop  (see  Cerebral 
Atroph\-  of  Children). 

The  prognosis  of  meningeal  hemorrhage  is  bad  unless 
the  clot  is  small  and  is  situated  over  the  convexity.  Re- 
covery ma)'  be  complicated  by  permanent  paralysis  (with  or 
without  convulsive  movements)  of  groups  of  muscles  upon 
the  side  opposite  to  the  lesion.  Death  from  meningeal 
hemorrhage  usually  occurs  earlier  than  from  cerebral 
hemorrhage. 


2.  DISEASES  OF  THE  BLOOD-VESSELS  OF   THE 

BRAIN. 

CONGESTION. 

Congestion  may  be  active  or  passive. 

Active  hypcncmia  may  be  due  to  exposure  to  the  sun,  to 
the  ingestion  of  such  drugs  as  alcohol,  amyl  nitrite,  and 
nitroglycerin,  to  excessive  brain-work,  to  reflex  causes,  or  to 
fever. 

Passive  /lyperceiiiia  results  from  (i)  mechanical  obstruc- 
tion to  the  venous  return  of  blood,  as  with  tumors  of  the 
neck  or  strangulation  ;  (2)  from  general  venous  congestion 
due  to  heart  or  lung  disease. 

The  symptoms  are  neither  characteristic  nor  constant. 
The  active  congestion  causes  headache,  a  sense  of  fulness 
and  throbbing  in  the  head,  and  hyperaisthesia  of  the  special 
senses.  The  face  is  flushed  ;  the  superficial  arteries  pulsate 
visibly.  Passive  hyperaemia  gives  rise  to  dull  headache,  to 
mental  slowness,  to  disturbances  of  sleep,  and  to  a  feeling 
of  fulness  in  the  head.  Attacks  of  delirium  or  unconscious- 
ness may  attend  the  severer  forms  of  congestion. 

Treatment. — The  patient  should  be  kept  quiet,  and  the 
bowels  should  be  freely  moved.  Venesection  may  be  in- 
dicated in  acute  congestion  of  an  intense  type,  and  an  ice- 
cap should  be  applied  to  the  head.  In  passive  hyperaemia 
the  treatment  should  be  directed  toward  the  cause  of  the 
condition. 


CEREBRAL    IfEMOR J< I/.ICE.  6ycj 

ANEMIA. 

Anaemia  may  result  from  general  or  local  causes.  Local- 
ized anaemia  may  be  due  to  vaso-motor  constriction,  en- 
darteritis, or  cerebral   compression. 

Symptoms. — Acute  anaemia,  such  as  results  from  pro- 
fuse hemorrhage,  gives  rise  to  confusion  of  ideas,  marked 
dyspnoea  amounting  to  "  air-hunger,"  spots  before  the  eyes, 
ringing  noises  in  the  ears,  a  tendency  to  yawn,  nausea,  and 
dilated  pupils.  Convulsions  and  syncope  may  occur.  Sud- 
den death  in  syncope  may  result  from  an  intense  anaemia 
suddenly  induced. 

Chronic  anaemia  is  characterized  by  vertical  headache, 
disturbances  of  sleep,  lack  of  mental  power  and  concen- 
tration. There  are  spots  before  the  eyes  and  buzzing  in 
the  ears.  There  may  be  repeated  syncopal  attacks.  The 
symptoms  are  regularly  relieved  by  lying  down. 

The  treatment  is  that  of  anaemia. 

OEDEMA. 

CEdema  may  be  due  (i)  to  atrophy  of  the  cerebral  cortex, 
there  being  an  increase  of  the  cerebro-spinal  fluid  and 
oedema  of  the  overlying  pia :  to  such  a  condition  the 
term  "wet  brain"  has  been  applied;  (2)  to  long-continued 
passive  congestion ;  (3)  localized  oedema  occurs  about 
tumors  and  abscesses  ;  (4)  oedema  may  occur  during  the 
advanced   stages   of  Bright's   disease. 

The  symptoms  are  obscure,  and,  in  general,  are  due  to 
the  disease  to  which  the  oedema  is  secondary. 

CEREBRAL   HEMORRHAGE  (APOPLEXY). 

Etiology. — Cerebral  hemorrhage  usually  occurs  after  the 
age  of  forty,  the  age  of  the  greatest  liability  being  between 
the  seventieth  and  eightieth  years.  More  rarely  the  disease 
occurs  in  children  and  in  young  adults.  The  condition  is 
more  common  in  males  than  in  females.  An  "apoplectic 
habit "  has  been  described — a  short,  thick-set  body,  wath 
flushed  face,  prominent  color,  and  short  neck,  but,  as  a 
matter  of  fact,  hemorrhage  is,  if  anything,  more  common 


68o     A/.i.vr.ii.  OF  THE  practice  of  mediclxe. 

to  those  of  spare  habit.  In  ahnost  all  cases  there  occurs 
degeneration  of  the  cerebral  arteries,  rendering  them  liable 
to  rupture.  Fatty  degeneration,  atheroma,  or  the  weaken- 
ing of  an  artery  from  an  embolus  may  be  found,  but  the 
most  frequent  cause  of  hemorrhage  is  an  endarteritis  which 
allows  of  the  production  of  miliary  aneur\-sms,  from  whose 
rupture  the  hemorrhage  takes  place.  These  miliary  an- 
eurysms occur  with  greatest  frequency  upon  the  middle  cere- 
bral artery  ;  thc\'  vary  in  size  up  to  that  of  a  pin's  head.  The 
predisposing  causes  for  the  endarteritis  are  gout,  syphilis, 
alcoholism,  and  a  life  of  over-work  and  privation.  There 
may  be  an  inherited  tendency  toward  arterial  degeneration. 
The  exciting  cause  for  rupture  is  an  increased  arterial  ten- 
sion. As  high  tension  so  frequently  occurs  with  chronic 
nephritis  and  hypertrophy  of  the  left  ventricle,  the  associa- 
tion of  these  conditions  with  cerebral  hemorrhage  is  ex- 
ceedingly common.  A  sudden  increase  of  blood-tension 
may  occur  from  strain,  fright,  anger,  a  cold  bath,  or  over- 
eating or  drinking.  In  other  cases  the  hemorrhage  may 
occur  during  rest  or  sleep. 

Cerebral  hemorrhage  in  young  adults  may  be  associated 
with  congenital  lack  of  development  of  the  aorta  and  large 
vessels.  Hemorrhage  may  occur  during  the  course  of 
hemorrhagic  disease,  as  leukaemia,  pernicious  anaemia,  and 
purpura  haemorrhagica,  but  these  hemorrhages  are  usually 
multiple  and  have  no  especial  seat  of  selection. 

Pathology. — Cerebral  hemorrhage  usually  occurs  from 
the  middle  cerebral  artery,  and  involves  the  internal  cap- 
sule, optic  thalamus,  corpus  striatum,  and  the  neighboring 
brain-tissue.  Next  in  frequency  are  hemorrhages  into  the 
cortex,  pons,  and  cerebellum.  The  right  side  is  more  fre- 
quently involved  than  the  left.  Should  the  hemorrhage 
occur  near  the  cortex,  the  blood  ma\-  rupture  through  and 
appear  beneath  the  dura.  Rupture  into  a  ventricle  may 
also  occur.  The  clot  at  first  is  red,  soft,  and  admixed  with 
lacerated  brain-tissue.  Gradually  the  clot  becomes  firmer, 
the  haemoglobin  becomes  converted  into  reddish-brown 
haematoidin,  the  disintegrated  brain-tissue  undergoes  fatty 
degeneration  and  absorption,  and  a  connective-tissue  capsule 


CKREBA'AL    IIKArORNI/AGE.  68 1 

may  form  about  the  hemorrhagic  mass.  Ultimately  there 
may  be  left  a  pigmented  puckered  cicatrix,  or  a  mass  of 
softened  pigmented  tissue  with  or  without  a  connective- 
tissue  wall,  or  a  cyst  with  brownish  fluid  contents.  The 
torn  brain  never  unites.  From  the  point  of  laceration  sec- 
ondary degeneration  occurs,  upward  to  the  cortex  if  the 
sensory  tract  be  involved,  downward  in  the  motor  tract  as 
far  as  the  anterior  motor  cells  of  the  spinal  cord  if  the 
lesion  involve  motor  fibres  (see  Secondary  Lateral  Scle- 
rosis). 

The  symptoms  depend  upon  the  size,  rapidity,  and  posi- 
tion of  the  hemorrhage.  The  symptoms  are  the  prodromal, 
those  of  the  attack,  and  those  of  the  chronic  stage. 

Prodromal  syviptonis,  which  are  due  to  the  cerebral  endar- 
teritis, consist  of  headache,  dizziness,  ringing  in  the  ears,  and 
irritability  of  temper.  More  characteristic  are  temporary 
loss  of  speech,  incomplete  temporary  paralysis  of  an  arm  or 
a  leg,  or  temporary  and  partial  blindness. 

Symptoms  of  the  Attack. — The  patient,  without  warning, 
becomes  dizzy  and  falls  unconscious.  In  other  cases  coma 
may  be  developed  gradually,  or  may  be  preceded  by  forget- 
fulness  and  mental  aberration.  The  face  is  flushed ;  the 
arteries  of  the  neck  pulsate  visibly ;  respirations  are  slow 
and  stertorous,  and  may  be  irregular;  the  eyes  and  the 
head  are  turned  toward  the  side  of  the  lesion  ("  conjugate 
deviation  ") ;  the  pupils  vary,  but  are  usually  dilated  and  in- 
active ;  the  pulse  is  full,  slow,  and  of  high  tension ;  the  tem- 
perature at  the  time  of  onset  falls  to  subnormal,  but  within 
twenty-four  hours  it  begins  to  rise.  The  more  severe  the 
hemorrhage,  the  greater  is  the  initial  fall  and  the  higher  the 
subsequent  rise.  Evidences  of  paralysis  may  be  discovered  : 
the  mouth  may  be  drawn  from  the  paralyzed  side ;  the 
paralyzed  cheek  may  blow  out  during  respiration  more  than 
the  other  cheek,  and  the  naso-labial  fold  may  be  obliterated. 
Hemiplegia  may  be  discovered  by  finding  that  the  affected 
arm  and  leg  drop  more  "  dead  "  than  do  those  of  the  un- 
paralyzed  side,  and  lack  their  normal  "  tone."  The  urine 
may  contain  a  trace  of  albumin  or  of  sugar,  even  if  there  be 
no  nephritis. 


682         MAXCAL    OF   THE   PRACTICE    OF  MEDICINE. 

Small  hemorrhages  slowly  developing  may  cause  no 
actual  coma,  but  bewilderment  and  mental  confusion  are 
commonly  observed  in  these  cases.  Hemorrhages  in  the 
cortex  or  into  a  ventricle  may  cause  convulsions  at  the  onset, 
but  these  cases  are  uncommon.  In  this  condition  of  coma 
the  patient  ma\'  die,  from  involvement  of  the  vital  functions 
or  from  hypostatic  pneumonia  and  pulmonary  oedema. 

Symptoms  of  the  Chronic  Stage. — When  the  attack  does 
not  prove  fatal,  consciousness  becomes  gradually  restored 
and  the  reflexes  return,  and  it  becomes  possible  to  gauge 
the  extent  of  the  damage  done  by  the  hemorrhage.  The 
symptoms  of  motor  paralysis  depend  upon  the  extent  to 
which  the  motor  tract  is  lacerated.  If  the  hemorrhage  be 
in  its  usual  location,  there  remains  a  hemiplegia  of  the  op- 
posite side.  The  muscles,  however,  are  not  uniformly  par- 
alyzed. Those  muscles  used  automatically  and  in  pairs,  as 
the  muscles  of  respiration,  escape  paralj'sis  ;  the  arm  is  more 
paralyzed  than  the  thigh,  the  hand  and  foot  more  than  the 
arm  and  leg.  If  recovery  ensue,  the  larger  and  more  auto- 
matic muscles  improve  more  rapidly  and  completely,  the 
leg  before  the  arm,  the  arm  before  the  hand.  An  "  initial 
rigidity  "  of  the  paralyzed  muscles  is  due  to  irritation  about 
the  lesion.  An  "  early  rigidity  "  may  develop  on  the  second 
or  third  day  and  may  last  for  one  or  two  weeks  ;  this  rigidity 
is  due  to  inflammation  about  the  lesion.  In  early  rigidity 
the  position  of  the  limbs  is  one  of  rest.  "  Late  rigidity  " 
appears  after  several  weeks  and  is  usually  permanent.  It  is 
due  to  descending  degeneration  of  the  motor  tract  (see  Sec- 
ondary Lateral  Sclerosis).  The  position  of  the  affected 
limb  is  generally  one  of  flexure.  Slow  convulsive  twitch-, 
ings  may  occur  in  the  paralyzed  muscles;  this  "post-hcmi- 
plegic  chorea  "  is  due  to  destructive  lesions  of  the  optic  thala- 
mus. During  late  rigidity  the  reflexes  of  the  affected  limbs 
are  greatly  exaggerated.  Atrophy  of  the  paralyzed  muscles 
does  not  occur.  Facial  paralysis  occurs  with  hemiplegia  in 
lesions  of  the  internal  capsule,  but  the  eyes  can  be  closed. 
The  tongue  deviates  when  protruded  toward  the  paralyzed 
side.  Aphasia  of  some  kind  may  accompany  right  hemi- 
plegia or  may  occur  alone.     Hcmiana;sthesia  develops  after 


CERI'inRAL    HF.ArORKJ/A  GE. 


683 


lesions  of  the  posterior  portion  of  the  internal  capsule,  but 
is  seldom  absolute  or  permanent.     Mental  symptoms  attend 


Fig.  55. — The  motor  tract  (Starr):  S,  fissure  of  Sylvius  :  NL,  lenticular  nucleus;  OT, 
optic  thalamus  ;  NC.  caudate  nucleus  ;  C,  crus  ;  P,  pons  ;  M,  medulla  ;  O,  olivary  body. 
The  tracts  for  face,  arms,  and  legs  gather  from  the  lower,  middle,  and  upper  thirds  of  the 
motor  area,  pass  into  the  capsule,  and  through  the  crus  and  pons,  where  the  face-fibres  cross 
to  the  opposite  VII.  N.  nucleus,  while  the  others  pass  on  to  the  lower  medulla,  where  they 
partially  decussate  to  enter  the  lateral  column  of  the  cord,  the  non-decussating  fibres  pass- 
ing into  the  ant.  median  columns.  Lesion  in  cortex  causes  monoplegia  ;  in  capsule,  hemi- 
plegia; in  pons,  alternating  paralysis. 


recovery  in  the  majority  of  cases,  and  consist  of  irritability 
of  temper,  imperfect  memory,  bewilderment,  delirium,  or 
even  dementia.  These  mental  symptoms  may  clear  away  or 
may  remain.  Crossed  facial  paralysis  occurs  with  destruc- 
tive lesions  of  the  lower  portion  of  the  pons  (see  Fig.  55)- 
Small  hemorrhages  in  the  cortex  cause  monoplegia  accord- 
ing to  their  situation.  Hemianopsia  occurs  if  the  lesion  in- 
volve the  optic  tracts  or  the  cuneus. 

Prognosis. — Small  hemorrhages   in  the   cortex  may  be 
recovered  from  without  extensive  or  permanent  paralysis. 


684      M.i.YL.u.  (.>/■  JJU:  j'K.tcnc/-:  o/-'  medici.xe. 

If  the  speech-centre  be  involved,  some  degree  of  aphasia 
may  remain.  Large  central  hemorrhages  rupturing  into 
the  ventricles  are  rapidly  fatal.  Hemorrhages  into  the  basic 
ganglia  and  the  internal  capsule  may  be  fatal.  In  case  of 
recovery  from  the  coma,  permanent  hemiplegia  with  con- 
tracture is  the  result.  Coma  persisting  for  more  than  forty- 
eight  hours,  congestion  and  oedema  of  the  lungs,  low  initial 
temperature  and  high  secondary  rise  with  delirium  and 
stupor,  albuminuria,  and  the  rapid  formation  of  atrophic 
bed-sores  are  indications  of  a  speedy  termination. 

Treatment. — The  patient  should  be  kept  quiet,  with  the 
head  high.  Ice  may  be  applied  to  the  head,  and  hot  bottles 
to  the  feet.  In  robust  patients  with  liigh  arterial  tension 
venesection  should  be  resorted  to ;  but  this  is  contra- 
indicated  if  the  blood-tension  is  low  and  the  pulse  is  weak. 

If  the  tongue  falls  back  and  mucus  collects  in  the  throat, 
the  patient  should  be  rolled  to  one  or  the  other  side. 
Many  patients,  according  to  Bowles,  are  allowed  to  suffocate 
from  lack  of  this  precautionary  procedure.  The  mouth 
should  be  cleansed  with  antiseptic  solutions  to  diminish  the 
danger  of  septic  broncho-pneumonia.  A  laxative  should  be 
given  at  the  onset — i  or  2  drops  of  croton  oil  or  \  grain  of 
elaterium.  For  throbbing  pulse  and  high  tension  aconite 
may  be  given  if  venesection  cannot  be  performed. 

The  paralyzed  limbs  should  be  massaged  to  maintain 
their  nutrition.  Faradism  is  indicated  after  the  lapse  of  one 
or  two  weeks,  but  when  paralysis  has  lasted  for  several 
months  and  late  rigidity  with  contracture  has  occurred, 
further  use  of  electricity  is  hopeless. 

EMBOLISM  OF  THE  CEREBRAL  ARTERIES. 
Etiology  and  Synonym. — The  usual  origin  of  the  em- 
bolus is  from  the  valves  of  the  left  heart ;  less  frequently 
the  embolus  arises  from  aneurysm  or  atheroma  of  the  aorta 
or  the  great  vessels  of  the  neck,  or  from  the  lungs.  The 
embolus  may  be  part  of  a  thrombus  that  has  formed  in  the 
auricular  appendi.x,  most  commonly  associated  with  the 
puerperal  state.  Septic  emboli  occurring  during  the  course 
of  ulcerative  endocarditis  and  abscess  of  the  lung  give  rise 


EMBOLISM   OF   -riJK    CERKBRAL    .lA'TEA'/ES.        685 

to  cerebral  abscesses,  and  will  be  considered  under  that 
heading.  Embolism  is  most  frequent  in  young  adults,  and 
both  sexes  are  affected  in  about  equal  proportions,  although, 
according  to  the  statistics  of  some  authors,  the  condition 
seems  more  prevalent  among  women.  Synonym  :  Cerebral 
softening. 

Pathology. — The  middle  cerebral  artery  or  one  of  its 
branches  is  occluded  in  90  per  cent,  of  all  cases,  the  left 
artery  being  more  frequently  involved  than  the  right.  Less 
frequently  are  involved  the  basilar,  posterior  cerebral,  ver- 
tebral, anterior  cerebral,  and  the  internal  carotid.  As  col- 
lateral circulation  is  never  sufficient  to  maintain  the  nutrition 
of  the  brain-tissue  whose  blood-supply  is  suddenl}'  cut  off 
by  the  occlusion  of  its  nutritive  artery,  softening  and  de- 
generation ultimately  result.  The  nerve-elements  are  infil- 
trated with  serum  and  undergo  fatty  degeneration.  If  the 
affected  area  be  the  seat  of  a  reflux  of  venous  blood,  it  will 
be  stained  red — "  red  softening ;"  later,  when  the  hemo- 
globin becomes  altered,  "yellow  softening"  results.  If 
there  be  no  reflux  of  blood,  "  white  softening"  results.  No 
matter  what  the  color  of  the  softened  spot  may  be,  the 
actual  disease  process  is  the  same  in  all  cases.  The  soften- 
ing process  proceeds  rapidly  and  is  usually  complete  in  one 
or  two  days.  The  area  of  softening  may  remain  unchanged 
for  considerable  time,  or  may  be  absorbed,  leaving  a  cicatrix 
which  may  be  pigmented.  In  other  cases  the  softened  area 
is  replaced  by  a  cyst  with  connective-tissue  walls. 

The  symptoms  depend  upon  the  artery  occluded. 

I.  Embolisin  of  the  Middle  Cerebral  Artery. — {a)  The  oiiset 
differs  from  that  of  hemorrhage  in  the  following  particulars  : 
(i)  There  are  no  premonitory  symptoms  ;  (2)  the  onset  is 
more  sudden  ;  (3)  coma  is  less  complete  and  is  shorter  in  du- 
ration ;  (4)  in  many  cases  unconsciousness  is  not  lost,  but  the 
patient  becomes  dizzy  and  bewildered  ;  (5)  convulsive  move- 
ments of  muscles  ultimately  to  be  paralyzed  occur  in  one- 
quarter  of  the  cases ;  (6)  there  are  no  signs  of  cerebral  com- 
pression ;  vomiting,  hard  pulsating  arteries,  slow  pulse, 
flushed  face,  and  stertor  consequently  do  not  appear;  (7) 


686        .y.L\L'.lL    OF   THE   PRACTICE    OE  MEDICEVE. 

the  initial  temperature-changes  are  sliglit,  but  in  a  few  days 
fever  may  develop 

{b)  Pcrmaucut  Syiiif^foiiis. — If  the  trunk  of  the  middle 
cerebral  artery  be  blocked,  hemiplegia  and  paralysis  of  the 
face  and  tongue  occur  on  the  side  opposite  to  the  lesion. 
There  may  be  aphasia  if  the  left  cerebral  artery  is  occluded. 
Attempts  at  collateral  circulation  are  attended  by  a  decided 
improvement  in  the  patient's  condition  in  from  twelve  to 
thirty-six  hours.  The  improvement  may  continue  or  may 
be  but  temporary.  The  sudden  onset  of  hemiplegia,  the  tem- 
porary improvement,  and  the  relapse  arc  characteristic  of 
embolism.  The  subsequent  course  resembles  that  following 
hemorrhage.  The  mind  in  embolism,  however,  is  less  fre- 
quently affected.  If  the  embolus  lodges  in  a  small  cortical 
artery,  the  softening  will  be  of  a  small  area,  so  that  mono- 
plegia or  aphasia  alone  may  develop.  In  these  cases  the 
stage  of  onset  may  not  be  well  marked. 

The  following  symptoms  follow  occlusion  of  the  other 
arteries  : 

2.  Vertcbi'al  Artery. — Symptoms  of  acute  bulbar  paralysis 
occur,  leading  to  speedy  death. 

3.  Basilar  Artery. — There  is  bilateral  paralysis  with  spasm 
and  rigidit)'.  S\-mptoms  of  acute  bulbar  paralysis  occur, 
and  death  follows  with  a  high  ante-mortem  temperature. 

4.  Inter ua/  Carotid  Artery. — Owing  to  perfect  anastomosis, 
no  symptoms  may  result.  In  other  cases  a  transient  or 
permanent  hemiplegia  may  develop. 

5.  Anterior  Cerebral  Artery. — No  symptoms  may  result, 
or  there  may  be  mental  weakness. 

Diagnosis  from  cerebral  hemorrhage  : 


Hemorrhage. 
Adults  between  40  and  80. 
Hypertrophied  heart. 
Endarteritis. 

Right  middle  cerebral  usually. 
Aphasia  less  often. 
Monoplegia  rare. 
Prodromal  symptoms. 
Coma  profound. 
Convulsions  rare. 
Cerebral  compression. 


Embolism. 
Young  adults. 
Endocarditis  usual. 
Not  essential. 
Left  middle  cerebral. 
Aphasia  more  often. 
Monoplegia  common. 
No  ]irodromal  symptoms. 
Coma  slight,  transient,  or  absent. 
Convulsions  in  25  per  cent. 
No  cerebral  compression. 


ANEURYSM  OF    'JlIE    CEREBRAL    AR'JER/ES.         68/ 

The  prognosis  as  regards  the  attack  is,  as  a  rule,  some- 
what better  than  in  hemorrhage.  From  the  resulting  paralysis 
recovery  is  not  usualy,  to  be  expected. 

The  treatment  resembles  that  of  hemorrhage,  except  that 
venesection  should  not  be  resorted  to.  Active  purgation  is 
not  necessary,  as  in  hemorrhage.  The  heart's  action  is 
often  so  weak  and  irregular  as  to  require  the  use  of  stim- 
ulants and  digitalis. 

THROMBOSIS  OP  THE  CEREBRAL  ARTERIES. 

Etiology. — Thrombi  may  form  in  an  artery  from  disease 
of  its  wall,  from  embolism,  or  from  pressure  on  the  vessel, 
as  from  a  tumor.  Thrombosis  may  also  occur  after  ligation 
of  the  internal  carotid  artery. 

The  patholog-y  resembles  that  of  embolism,  except  that 
the  softening  occurs  more  gradually ;  otherwise  the  results 
of  the  two  conditions  are  identical.  The  middle  cerebral 
and  basilar  arteries  are  those  most  commonly  affected. 

The  symptoms  resemble  those  of  embolism,  but  they 
appear  more  gradually.  There  may  be  premonitory  symp- 
toms— vertigo,  transient  aphasia  or  hemiplegia,  and  drowsi- 
ness. Hemiplegia  slowly  develops,  taking  several  hours  for 
its  completion,  and  the  patient  gradually  becomes  comatose. 

The  prognosis  and  treatment  are  those  of  embolism, 

ANEURYSM  OP  THE  CEREBRAL  ARTERIES. 

Etiology. — The  condition  occurs  in  middle  age  and  is 
more  frequent  in  men.  The  etiology  is  that  of  endarteritis 
and  aneurysm  in  general.  In  many  cases  aneurysm  follows 
embolism,  the  embolus  disappears,  and  dilatation  follows 
the  secondary  inflammatory  changes  in  the  coats  of  the 
artery. 

Pathology. — The  aneurysm  occurs  most  frequently  on 
the  central,  basilar,  and  internal  carotid,  less  frequently 
upon  any  of  the  branches  of  the  circle  of  Willis.  The 
aneurysm  is  usually  small,  rarely  exceeding  the  size  of  a 
cherry,  and  is  usually  sacculated. 

The   symptoms  are  those  of  tumor  at  the  base  of  the 


688        M.lXr.lL    OF  THE   PRACriCE    OF  MEDICINE. 

brain,  and  hemorrhage.  The  pressure-symptoms  are  those 
of  a  small  basal  tumor,  the  involvement  of  the  cranial  nerves 
being  especiall\-  frccjuent.  Of  suspicious  significance  is  the 
occurrence  of  crossed  hemiplegia  and  third-nerve  paral\'sis. 
The  accompanying  illustration  (Fig.  56)  shows  that  only 
pressure  on  one  crus  could  cause  such  a  distribution  of 
paralysis,  and  the  most  likely  thing  to  press  on  the  crus  is 
an  aneurysm  at  the  base  of  the  brain. 


OP.    th 


^x 


Fig.  56. — Diagram  of  a  section  through  the  crus.  etc.,  in  front  of  the  corpora  quadrigemina 
(modified  from  Wernicke)  :  P  C,  posterior  commissure;  Aq,  aqueduct  of  Sylvius;  P  L, 
posterior  longitudinal  fibres;  III.,  third  nerve;  LB,  Luy's  body;  OPT,  optic  tract; 
A,  aneurysm  causing  compression-paralysis  of  third  nerve  on  same  side,  and  opposite 
hemiplegia. 


The  symptoms  of  rupture  lead  quickly  to  a  fatal  issue, 
and  the  sudden  occurrence  of  a  large  meningeal  hemor- 
rhage at  the  base  of  the  brain  is  the  first  information  of  the 
disease  in  the  majority  of  cases. 

The  prog-nosis  is  exceedingly  bad. 

Treatment. — If  the  diagnosis  of  aneurysm  be  made,  the 
patient  is  to  be  put  to  bed,  the  circulation  is  to  be  rendered 
tranquil,  and  iodide  of  potassium  is  to  be  given  as  for  aortic 
aneurysm.  The  vertebral  or  the  internal  carotid  artery  may 
be  ligated  as  an  extreme  measure,  but  the  results  of  such 
surgical  Jireatment  are  not  good. 


TIIROMBOSfS    OF   THE    VENOUS  SINUSES.  689 


THROMBOSIS  OF  THE  VENOUS  SINUSES. 

Btiolog-y. — Primary  or  marantic  thrombosis  occurs  as  a 
terminal  event  in  cachectic  conditions,  and  is  not  infrequent 
in  the  aged.  Infants  during  the  first  six  months  of  Hfc  may 
be  affected,  usually  after  exhausting  diarrhoial  diseases. 

Secondary  thrombosis  complicates  embolism  and  cerebral 
tumors  producing  pressure  upon  a  sinus.  In  these  cases 
the  clot  is  not  septic. 

Septic  thrombus  occurs  with  disease  or  injury  of  the 
cranial  bones  or  of  the  middle  ear,  with  meningitis,  and  with 
suppurative  disease  or  erysipelas  of  the  scalp,  face,  or  orbit. 

Pathology, — The  effect  of  a  clot  within  a  venous  sinus 
or  a  vein  is  to  cause  intense  congestion  and  oedema  of  the 
brain-territory  the  circulation  of  which  thus  becomes  ob- 
structed. Softening  of  the  brain-tissue  may  ultimately 
result.  Septic  thrombi  soften,  break  down,  and  may  give 
rise  to  embolic  abscesses  or  to  purulent  meningitis. 

Symptoms.  —  General  cerebral  symptoms,  which  are 
usually  present,  consist  of  apathy,  stupor,  delirium,  con- 
vulsions, muscular  rigidity,  vomiting,  optic  neuritis,  and 
coma.  Localizing  symptoms  do  not  usually  occur.  The 
cerebral  symptoms  are  most  marked  when  the  superior 
longitudinal  sinus  is  involved,  but  they  are  never  character- 
istic. Of  diagnostic  importance  are  oedema  and  distention 
of  the  veins  outside  the  skull,  in  the  parts  from  which  the 
veins  pass  through  the  bones  to  join  the  internal  sinuses,  as 
in  the  following  instances :  Thrombosis  of  the  superior 
longitudinal  sinus  causes  congestion  and  oedema  of  the  sides 
of  the  head  and  forehead,  prominence  of  the  anterior  fonta- 
nelle  in  children,  and  epistaxis.  Thrombosis  of  the  caver- 
nous si7ins  causes  oedema  and  congestion  of  the  eyelid  and  a 
prominence  of  the  eyeball.  Thrombosis  of  the  lateral  sinus 
causes  oedema  and  congestion  over  the  mastoid. 

Septic  thrombi  give  rise  to  septic  symptoms — chills,  in- 
termittent or  remittent  pyrexia,  and  the  "typhoid  state." 
The  course  of  the  disease  may  be  complicated  by  menin- 
gitis or  abscesses  of  the  brain. 

4-i 


690       M.lXi'AL    OF  THE   PRACTICE    OF  MEDICINE. 

The  duration  of  the  disease  is  from  a  few  days  to  several 
weeks. 

The  prognosis  is  bad,  except  that  in  case  of  small,  non- 
septic  thrombi  recover}'  may  be  possible. 

Treatment. — The  shoulders  and  the  head  should  be 
raised  in  bed  to  facilitate  the  venous  outflow  of  blood.  The 
lateral  sinus  has  been  explored  and  septic  clots  removed, 
with  recovery.     Otherwise  the  treatment  is  symptomatic. 

CEREBRAL   ENDARTERITIS. 

Etiolog-y. — Cerebral  endarteritis  usually  occurs  in  males, 
and  is  a  disease  of  middle  and  advanced  life.  The  condi- 
tion may  be  due  to  senile  degeneration  of  the  arteries, 
chronic  alcoholism,  gout,  syphilis,  or  chronic  nephritis. 

The  pathology  is  that  of  endarteritis  (see  Arterio-cap- 
illary  Fibrosis).  The  walls  of  the  cerebral  arteries  are 
thickened  and  rigid,  and  may  be  the  seat  of  atheroma  or  of 
fatty  degeneration.  Increased  connective  tissue  in  the  intima 
may  lead  to  occlusion  ("obliterating  endarteritis  ").  Such 
degenerated  arteries  cause  an  irregularly  diminished  supply 
of  blood  to  the  brain,  are  subject  to  spasm,  and  may  lead 
to  softening  of  the  brain,  to  miliary  aneurysms  and  hemor- 
rhage, or  to  larger  aneurysms  of  any  of  the  cerebral  arteries. 

Symptoms. — Three  groups  of  clinical  S}-mptoms  may  be 
described : 

•  I.  Symptoms  of  Brain-ancpviia. — The  patient  suffers  from 
headache,  dizziness,  spots  before  the  eyes,  and  buzzing 
noises  in  the  ears,  and  becomes  unable  to  concentrate  the 
mind  for  any  length  of  time.  These  symptoms  are  com- 
mon to  brain-ansemia  from  any  cause. 

2,  Suddenly-induced  Aiuzmia  from  Spasm. — Spasm  may 
occur  without  known  cause  at  any  time,  or  may  follow 
mental  excitement  or  over-eating  or  drinking.  The  spasm 
is  most  common  in  the  middle  cerebral  artery.  In  mild 
cases  the  patient  will  suddenly  develop  a  partial  paralysis 
of  the  arm  or  leg,  or  will  become  aphasic.  Hemianopia 
may  occur.  The  onset  is  usually  accompanied  by  a  "  wave 
of  faintness  "  and  mental  bewilderment,  but  actual  loss  of 
consciousness  does  not  often  occur.     Spasm  may  precede 


CEREJSRAL    ENDAR'JKKITIS.  69 1 

the  muscular  weakness.  These  attacks  are  usually  tem- 
porary, lasting  but  an  hour  or  so  and  then  wearing  off;  they 
are  liable  to  be  repeated.  In  other  cases  the  spasm  leads  to 
softening  and  the  symptoms  become  permanent.  In  .severe 
cases  the  patient  loses  consciousness,  although  the  coma  is 
not  as  complete  as  in  hemorrhage  and  is  of  shorter  dura- 
tion. Hemiplegia  with  or  without  aphasia  develops,  and 
may  be  preceded  by  convulsive  movements  of  the  muscles. 
The  temperature  rarely  undergoes  initial  changes,  and  there 
are  no  symptoms  of  compression  (slow  pulse,  stertor, 
flushed  face,  and  throbbing  arteries),  as  in  hemorrhage.  The 
pulse  is  usually  of  high  tension,  owing  to  the  presence  of 
general  endarteritis  and  nephritis.  Under  favorable  circum- 
stances the  spasm  passes  off  and  recovery  takes  place  in  a 
few  hours  or  days. 

Illustrative  Case. — Male,  sixty-five  years  ;  chronic  nephri- 
tis, general  endarteritis.  2  p.  m.,  fell  unconscious  :  right 
hemiplegia,  aphasia  ;  pulse  70,  of  high  tension  ;  no  stertor  ; 
temperature  normal.  12  p.  m.,  conscious;  begins  to  move 
and  to  talk.  4  A.  m.,  walked  and  talked ;  is  rational.  6  a.  m., 
perfectly  recovered. 

3.  Symptoms  of  Brain-softening. — If  the  spasm  be  too  long 
continued,  or  should  a  thrombus  form  in  the  vessel,  the 
brain-tissue,  thus  deprived  of  its  blood-supply,  will  die  and 
soften  as  in  embolism  or  thrombosis.  A  similar  effect  is 
produced  by  obliterating  endarteritis.  In  these  cases  the 
patient  does  not  recover.  If  the  softened  area  be  extensive, 
the  patient  will  die  in  a  few  days  in  coma  with  hemiplegia, 
death  usually  being  due  to  pulmonary  oedema.  In  some 
cases  coma  is  not  marked  at  first,  so  that  paralysis  without 
loss  of  consciousness  is  regarded  as  indicative  of  acute  soft- 
ening from  arterial  obstruction,  however  produced.  If  a 
smaller  area  be  involved,  the  patient  will  live,  but  with  per- 
manent paralysis  or  aphasia.  In  these  cases  mental  de- 
rangement is  common. 

The  diagnosis  is  made  by  the  presence  of  extensive 
arterial  degeneration,  by  the  history  of  previous  attacks  fol- 
lowed by  recovery,  by  the  absence  of  symptoms  of  cerebral 
compression,  by  the  absence  of  causes  for  embolism,  and  by 


692        MA.yr.lL    OF  THE   rJx\lCTICE    OF  MEDICINE. 

the  rapid  recovery  under  appropriate  treatment.  When 
softening  occurs  the  diagnosis  from  thrombosis  cannot  be 
made. 

Prognosis. — As  the  lesion  is  continuous  and  progressive, 
there  is  habihty  to  recurring  attacks  which  tend  to  become 
more  and  more  severe.  The  prognosis  is  rendered  worse 
by  the  nephritis,  by  the  atheroma  of  the  aorta  and  the 
coronary  arteries,  and  by  the  chronic  alcohohsm  if  such  a 
habit  exists.  The  danger  of  hemorrhage  must  also  be  con- 
sidered. The  immediate  prognosis  during  an  attack  de- 
pends upon  the  duration  of  the  spasm  and  upon  the  chances 
of  a  thrombus  forming  in  the  vessel ;  a  positive  assurance 
of  recovery,  therefore,  should  never  be  made. 

Treatment. — Between  attacks  the  treatment  should  be 
directed  toward  the  arterial  degeneration  (see  Arterio-capil- 
lary  Fibrosis).  For  the  anaemic  symptoms  the  arteries  may 
be  relaxed  with  small  doses  of  potassium  iodide,  nitro- 
glycerin, or  chloral  hydrate.     Digitalis  is  contraindicated. 

At  the  time  of  spasm  the  arterial  dilators  above  mentioned 
should  be  pushed  to  physiological  limits.  The  bowels 
should  be  moved,  and  the  functions  of  the  skin  and  kidney 
should  be  stimulated,  to  eliminate  from  the  system  such 
noxious  products  as  might  cause  arterial  spasm. 

Whcji  actual  softening  occurs  treatment  becomes  inopera- 
tive. 


3.  DISEASES  OF  THE  BRAIN-SUBSTANCE, 

CEREBRAL  LOCALIZATION. 
Cortical  Areas. —  i.  Tlie  motor  area  is  located  in  the 
cortex  of  the  anterior  and  posterior  central  convolutions 
bordering  upon  the  fissure  of  Rolando.  The  area  of  each 
hemisphere  controls  muscular  movements  of  the  opposite 
side  of  the  body.  The  different  groups  of  muscles  are 
supplied  by  definite  portions  of  the  motor  area,  as  is  shown 
by  the  accompanying  diagram  (Fig.  57).  Irritation  of  the 
motor  area  gives  rise  to  localized  spasm  or  convulsions 
("  Jacksonian  epilepsy  ").  Destructive  lesions  cause  paral- 
ysis.    Slowly  spreading  lesions,  as  the  growth  of  a  tumor, 


CEREBRA  L    L  O  CA  /.  IZA  TION. 


693 


cause  spreading  irritation  followed  by  destructive  symptoms 
(convulsions  followed  by  paralysis),  and  involve  fresh 
groups  of  muscles,  so  that  the  size  and  position  of  the 
lesion  may  be  determined  accurately.  Cortical  paralysis  is 
monoplegic  and  is  associated  with  increased  reflexes,  but 
the  paralyzed  muscles  do  not  atrophy  and  the  electrical 
reactions  are  unchanged.  Destructive  lesions  in  the  motor 
tract  from  the  cortex  to  the  anterior  nerve-cells  in  the  spinal 
cord  are  regularly  followed  by  descending  degeneration  (see 
Secondary  Lateral  Sclerosis). 

2.  The  sensory  area  is  in  the  cortex  posterior  to  the  motor 
area,  but  accuracy  in  localization  cannot  be  obtained.  The 
tactile  sensibility  of  muscles  seems  to  be  in  the  motor  area. 


Fig.  57. — The  functional  areas  of  the  brain,  left  hemisphere  (Starr). 


3.  The  visual  area  is  in  the  occipital  lobe,  including  the 
cuneus  on  the  median  surface  and  the  occipital  convolutions 
on  the  convexity  (see  Fig.  58).  Each  area  receives  impres- 
sions from  the  same  side  of  each  retina,  so  that  distinctive 
lesions  cause  failure  of  visual  perception  in  the  same  side 
of  each  retina,  the  blind  field  of  vision  being  therefore  on  the 
opposite  side  to  the  lesion  ("  homonymous  hemianopsia ;"  see 
Fig.  59).  Irritation  of  the  visual  area  causes  visual  halluci- 
nations. Destruction  of  the  visual  area  of  the  left  side  is 
followed  by  word-blindness. 

4.  The  auditory  area  is  in  the  first  and  second  temporal 


694 


MAXr.lL    OF   THE   PRACTICE    OF  MEDIChWE. 


convolutions.  Deafness  from  unilateral  lesions  is  seldom 
noticeable.  Lesions  of  the  auditory  centre  on  the  left  side 
are  followed  by  auditory  amnesia,  or  word-deafness. 

5.  The  smell-  and  tastc-ccntrcs  are  found  at  the  tip  of  the 
temporal  lobe,  where  it  rests  upon  the  .sphenoid  bone.  Uni- 
lateral lesions  do  not  produce  noticeable  symptoms. 

6.  The  speech-centres  are  found  in  the  left  hemisphere  in 
right-handed  people,  in  the  right  hemisphere  in  those  who 


Fig.  58. — Inner  surface  of  right  hemisphere:  A,  ascending  frontal,  B,  ascending  parietal 
convolution  ;  <r,  terminal  portion  of  the  sulcus  centralis,  or  fissure  of  Rolando  ;  CC,  corpus 
callosum,  longitudinally  divided;  C/",  collateral  or  occipito-temporal  fissure  (Ecker) ;  cm, 
sulcus  calloso-marginalis  ;  D,  gj'rus  descendens  ;  F\,  median  aspect  of  the  first  frontal  con- 
volution;  C/",  gyrus  fornicatus ;  ^,  gyrus  hippocampi;  A,  sulcus  hippocampi,  or  dentate 
fissure;  O,  sulcus  occipitalis  transversus  ;  otr,  calcarine  fissure;  cc',  superior,  <7^',  inferior 
ramus  of  the  same ;  Oz,  cuneus  ;  po,  parieto-occipital  fissure  ;  P\' ,  precuneus  ;  T^,  gyrus 
occipito-temporalis  lateralis  (lobulus  fusiformis) ;  7\,  gyrus  occipito-temporalis  medialis 
(lobulus  lingualis)  ;    U,  uncinate  gyrus 

are  left-handed.  Reflex  and  automatic  speech  may  receive 
impulses  from  both  hemispheres.  There  are  four  speech- 
centres  : 

{a)  The  motor  speech-centre  is  in  the  posterior  portion  of 
the  third  left  frontal  convolution,  and  governs  the  motions 
concerned  in  talking.  Destructive  lesions  produce  loss  of 
the  memory  of  the  effort  needed  to  pronounce  a  word  ("  mo- 
tor aphasia  ").  Such  patients  cannot  talk  or  read  aloud,  but 
understand  what  is  said  to  them,  and  ma\'  be  able  to  write. 

{B)  The  auditory  speech-centre  is  in  the  first  and  second 
left  temporal  convolutions,  and  controls  the  understanding 
of  language  and  the  recollection  of  the  names  of  things. 
When  the  centre  is  destroyed  "word-deafness"  results. 


CEREBRAL   LOCALIZATION. 


695 


Fig.  59. — The  visual  tract  (Starr):  the  result  of  a  lesion  anywhere  between  the  chiasm 
and  the  cuneus  is  to  produce  homonymous  hemianopsia.  H,  lesion  at  chiasm  causing 
bilateral  temporal  hemianopsia;  iV,  lesion  at  chiasm  causing  unilateral  nasal  hemianopsia  ; 
T,  lesion  at  chiasm  causing  unilateral  temporal  hemianopsia  ;  SN,  substantia  nigra  of  crus  ; 
L,  lemniscus  in  crus  ;  RN,  red  nucleus;  ///.,  third  nerves. 

ic)  The    visual  specch-cenU'e  is   in  the    cuneus    and   the 
occipital  convolutions.     When  destroyed  "  word-blindness  " 


696        MAXr.tL    OF   THE   PRACTICE    OF  MEDICINE. 

results,  the  patient  being  unable  to  understand  written  lan- 
guage. 

(</)  The  ivriting  speech-centre  is  supposed  to  be  within 
the  motor  speech-centre.  If  the  patient  be  unable  to  write, 
the  condition  is  termed  "  agraphia." 

Lesions  destroying  commissural  or  association  fibres  be- 
tween the  various  speech-centres  cause  displacement  of 
words,  so  that  the  patient  may  talk  jargon.  To  this  con- 
dition the  terms  "  mixed  aphasia  "  and  "  paraphasia  "  have 
been  applied. 

7.  The  intellectual  area  is  located  in  the  frontal  lobes,  but 
no  localizing  symptoms  occur. 

Subcortical    Localization. — Cent  nun     Ovale. — Lesions 


"ytvem 


Fig.  60. — The  sensory  tract  in  the 
cms,  pons,  and  medulla,  showing  nu- 
cleus and  roots  of  V.  nerve  (Starr) :  A, 
lesion  causes  hemiansesthcsia  ;  B,  lesion 
causes  alternating  hemiana;sthesia — left 
face  and  right  side  of  body. 


_a[NUOUl\s.U 


"VSi  NUClfUS. 


Fig.  61. — The  motor  tract  in  the  crus, 
pons,  and  medulla  (Starr) :  A,  lesion  causes 
hemiplegia;  B,  lesion  causes  alternating 
paralysis — left  facial,  right  extremities  ;  C, 
lesion  causes  paralysis  of  limbs  and  tongue  ; 
D,  lesion  causes  paralysis  of  limbs  of  oppo- 
site side ;  E,  lesion  in  motor  decussation 
causes  bilateral  paralysis. 


cause  paralysis,  which  are  hemiplegic  the  nearer  the  lesion 
is  to  the  internal  capsule,  monoplegic  the  nearer  to  the  cortex. 
Hemiana^sthesia  results  from  lesions  in  the  posterior  por- 
tion, and  hemianopsia  may  also  result. 


ABSCESS    OF   rilE   BKAIN.  697 

Internal  Capsule. — Lesions  of  the  anterior  two-thirds 
cause  opposite  hemiplegia,  with  involvement  of  the  tongue 
and  face  and  with  descending  degenerations  (see  Fig.  55). 
The  power  to  wink  is  maintained.  Lesions  of  the  posterior 
third  cause  hemiansesthesia. 

Lesions  of  the  lower  portion  of  the  pons  cause  crossed 
facial  paralysis  (see  Fig.  61).  The  facial  paralysis  resembles 
the  cerebral  form  in  that  the  lower  fibres  alone  are  involved. 

If  the  nucleus  of  the  facial  nerve  be  involved,  the  patient 
will  not  be  able  to  wink,  and  atrophy  and  the  reaction  of 
degeneration  will  be  developed.  Lesions  in  the  lower  por- 
tion of  the  pons  may  also  cause  alternating  hemianaesthesia 
(see  Fig.  60). 

Basic  Ganglia. — Destructive  lesions  cannot  be  diagnosed 
from  those  of  the  tracts  which  lie  near  them. 

Corpora  Qiiadrigeniina. — Destructive  lesions  cause  stag- 
gering gait,  blindness,  nystagmus,  and  ophthalmoplegia. 

Cerebellnm. — Lesions  cause  staggering  gait,  but  the  ataxia 
disappears  when  the  patient  lies  down.  Vertigo  is  marked. 
Irritation  of  the  middle  peduncle  causes  staggering  toward 
the  side  of  the  lesion  ;  destruction  of  the  middle  peduncle 
causes  staggering  away  from  the  side  of  the  lesion. 

ABSCESS    OF    THE    BRAIN  (SUPPURATIVE 
ENCEPHALITIS). 

Etiology. — Infection  of  the  brain-substance  may  occur 
through  the  following  channels  : 

1.  By  Contimdty  through  the  Cranial  Bones. — Thus  abscess 
arises  from  injury  of  the  scalp  or  skull  (35  per  cent.),  from 
caries  of  the  cranial  bones  (10  per  cent.),  from  diseases  of 
the  middle  ear  (40  per  cent),  or  from  chronic  suppurative 
rhinitis  (10  per  cent.).  In  these  cases  the  abscess  is  often 
associated  with  meningitis. 

2.  Through  the  Blood-vessels. — Septic  emboli  may  occur 
during  the  course  of  pyaemia,  malignant  endocarditis,  gan- 
grene, or  suppuration  of  the  lung  or  of  the  pleura.  Abscess 
of  the  brain  may  be  a  sequel  of  epidemic  influenza. 

Abscess  of  the  brain  usually  occurs  between  the  twentieth 


69S        M.LVi'AL    OF  THE   PRACTICE    OF  MEDICINE. 

and  fortieth  years,  and  is  more  common  in  men  than  in 
women. 

Patholog-y. — Abscess  is  most  common  in  the  temporo- 
sphenoidal  lobe.  One-eighth  of  the  cases  occur  in  the  cere- 
bellum and  r.re  usually  secondary  to  mastoid  disease.  The 
abscess  at  first  is  limited  by  jagged  and  necrotic  brain-tissue 
infiltrated  by  pus-cells,  or,  in  time,  a  fibrous  capsule  may  be 
formed.  Rupture  into  the  ventricles  may  result ;  rupture 
through  the  cortex  induces  a  peracute  meningitis.  The 
cerebral  sinuses  may  be  the  seat  of  infective  thrombi.  Em- 
bolic abscesses  are  usually  multiple.  Abscess  of  the  brain 
may  run  an  acute  or  a  chronic  course. 

The  syraptoms  of  acute  cases  may  be  divided  into  three 
groups  : 

1 .  Symptoms  of  Pressure. — Headache  is  severe  and  con- 
stant, persists  during  sleep  and  stupor,  and  may  be  localized. 
Vomiting  is  frequent  and  is  not  induced  by  eating.  Optic 
neuritis  commonly  develops.  The  pupils  are  apt  to  be  ir- 
regular. The  pulse  is  apt  to  be  slow,  running  from  60  to 
70.  Drowsiness  alternates  with  restlessness  and  delirium, 
and  finally  merges  into  coma. 

2.  Toxic  syinptoms  are  those  of  an  internal  abscess.  A 
chill  occurs  at  the  onset ;  chills  may  be  repeated  at  irregular 
periods  throughout  the  disease.  Irregular  fever  occurs,  but 
usually  there  are  periods  during  which  the  temperature  is 
normal  or  subnormal.  The  patient  finally  passes  into  the 
typhoid  condition. 

3.  Localizing  symptoms  depend  upon  the  location  of  the 
abscess,  and  whether  certain  portions  of  the  brain  are  irri- 
tated or  destroyed.  There  may  be  convulsions  (general  and 
epileptiform,  or  localized  in  certain  groups  of  muscles), 
paralyses  (either  hemiplegic  or  monoplegic),  or  aphasia.  If 
phlebitis  be  present,  there  will  be  oedema  behind  the  ear  and 
a  sense  of  fulness  over  the  jugular  vein.  If  meningitis  be 
present,  there  will  be  rigidity  of  the  neck  and  cranial-nerve 
paralysis. 

Abscesses  in  the  frontal  lobe  may  cause  only  a  mental 
dulness.  They  are  usually  caused  by  disease  of  the  nose 
or  of  the  ethmoidal  cells. 


TUMORS   Of    77//''.    J!/k'A/N.  699 

In  the  temporo-sphenoidal  lobe  there  may  be  no  locahzing 
symptoms.  Abscess  of  the  parieto-occipital  region  may  cause 
hemianopia. 

Cerebellar  abscess  is  usually  accompanied  by  vomiting, 
vertigo,  and  staggering  gait. 

A  chronic  abscess  may  develop  in  some  portion  of  the 
brain  that  is  not  highly  specialized  ("silent  region"),  become 
encapsulated,  and  lead  to  no  particular  symptoms.  After 
the  lapse  of  a  number  of  months,  however,  it  is  usual  for 
the  abscess  to  show  itself  by  sudden  coma  or  an  epileptic 
seizure.  These  terminal  phenomena  are  due  to  rupture 
either  into  a  ventricle  or  through  the  cortex. 

The  diagnosis  is  based  upon  the  presence  of  a  cause  by 
which  infection  is  possible,  upon  septic  symptoms,  and  upon 
the  symptoms  of  a  localized  destructive  lesion. 

Prognosis. — Acute  abscesses  terminate  in  from  three  to 
fourteen  days,  rarely  extending  over  thirty  days.  Chronic 
abscesses  may  have  a  latent  period  of  weeks  or  months,  but 
death  usually  takes  place  within  one  or  two  days  of  the 
rupture.  The  prognosis  is  fatal  unless  the  pus  can  be 
evacuated. 

Treatment  is  exclusively  surgical,  and  consists  of  tre- 
phining and  draining  the  abscess-cavity.  The  percentage 
of  cases  recovering  after  such  operation  is  increasing  year 
by  year. 

TUMORS  OF  THE  BRAIN. 
The  following  are  the  more  frequent  varieties  of  brain- 
tumors  encountered : 

1.  Tubercle. — Tubercular  tumors  are  usually  multiple, 
and  are  generally  found  in  the  cerebellum.  They  may  grow 
to  one  or  two  inches  in  diameter.  One-half  of  the  tumors 
in  children  are  of  tubercular  origin. 

2.  Glioma  is  a  form  of  tumor  peculiar  to  the  nervous 
system,  and  consists  of  a  fibrillary  network  and  branching 
cells.  A  variety  called  "  neuro-glioma "  contains  large 
spindle-cells  with  single  nuclei,  and  others  resembling  the 
large  ganglion-cells.  Gliomata  may  be  hard  and  may 
resemble    an    area    of  sclerosis,  or   they  may  be    soft   and 


700        MJXL'AL    OF   THE   PRACTICE    OF  MEDICLVE. 

highl)'  vascular.  Glioma  is  never  sharply  defined,  but 
fades  imperceptibK'  into  the  surrounding  bone-tissue,  hence 
its  invasive  tendency.  Glioma  and  sarcoma  are  often  com- 
bined.- 

3.  Syphilitic  f iiviofs,  or giiDiDiata,  :xrc  most  common  in  the 
hemispheres  and  pons,  and  usually  develop  from  the  pia 
mater  or  the  arteries.  Gummata  are  rarely  of  large  size 
and  are  usually  multiple. 

4.  Sairojiia  usually  develops  from  the  membranes  or  the 
cranial  bones,  and  may  reach  large  size.  Myxo-sarcomata 
are  not  uncommon. 

4.  Cancer  is  almost  regularly  of  secondary  growth,  and 
may  be  multiple.  Sarcoma  or  carcinoma  starting  from  the 
membranes  may  invade  the  bones  and  appear  externally, 
forming  the  "  fungus  haimatodes,"  or  "  perforating  tumor 
of  the   dura." 

6.  Cjsts  may  be  found,  resulting  from  previous  hemor- 
rhage or  from  defective  development.  Hydatid  cysts  are 
not  uncommon  in  certain  countries,  as  Iceland  and  Australia. 

Psamvwnia,  cholesteatoma,  lipoma,  and  angioma  are  rare 
forms  of  tumor.  An  aneurj'sm  of  one  of  the  cerebral  arteries 
forms  a  tumor  which  has  elsewhere  been  discussed. 

Patholog-y. — Except  for  tubercular  and  gliomatous 
tumors,  the  new  growth  usually  starts  in  the  membranes. 
According  to  Starr,  the  cerebral  cortex  is  involved  in  25 
per  cent.,  the  cerebellum  in  25  per  cent.,  the  centrum  ovale 
in  5  per  cent,  the  basic  ganglia,  the  pons,  the  crus,  and 
the  corpora  quadragemina,  each  in  10  per  cent.,  other  parts 
in  5  per  cent.,  of  all  cases.  The  brain-tissue  in  the  neigh- 
borhood of  a  tumor  may  be  hyperaemic  and  inflamed,  or  it 
may  undergo  softening.  A  localized  chronic  meningitis 
results  if  the  growth  involve  the  pia  mater.  If  the  venous 
sinuses  be  compressed,  the  blood  may  be  dammed  back, 
and  serous  effusion  may  take  place  within  the  cavity  of 
the  ventricles. 

Men  are  more  frequently  affected  than  women,  in  the 
proportion  of  2  :  i.  In  children,  tumors  are  apt  to  be 
tubercular;  in  early  life,  gummata  or  gliomata;  in  middle 
life,  sarcomata,   gummata,  or  gliomata ;  in  late   life,  sarco- 


TUMORS    OF   THE   BRAIN.  7OI 

mata,  gummata,  or  carcinomata.  Tumors  of  the  brain  are 
rare  after  the  age  of  sixty. 

The  symptoms  of  brain-tumors  may  be  divided  into  two 
groups:  (i)  Those  due  to  brain-compression,  no  matter 
where  the  growth  may  be ;  (2)  the  localizing  symptoms, 
due  to  localized  irritation  and  destruction  of  a  certain  por- 
tion of  the  brain. 

I.  General  symptoms  of  brain-compression  are  tolerably 
constant  in  all  cases  of  brain-tumor. 

{a)  Headaclie  occurs  in  95  per  cent,  of  all  cases.  It  is 
usually  dull  and  "  stupefying,"  with  paroxysmal  exacerba- 
tions, and  it  may  be  general,  or  localized  over  the  growth, 
especially  in  the  case  of  cerebellar  tumors.  There  may  be 
localized  tenderness  over  the  scalp.  The  headache  differs 
from  that  of  functional  origin  in  that  the  patient  gives 
evidence  of  pain  during  sleep  or  during  periods  of  stupor. 
The  headache  of  brain-tumor  is  more  severe  and  persistent 
than  that  of  any  other  disease. 

{B)  Mental  disturbances  occur  in  85  per  cent,  of  all  cases. 
The  patient  becomes  dull,  apathetic,  and  inattentive. 
Memory  and  reasoning  are  impaired ;  childishness  and 
even  dementia  or  insanity  may  develop.  The  characteristic 
speech  is  an  articulation  in  which  the  syllables  are  run  to- 
gether.    In  many  cases  there  are  morbid  erotic  desires. 

[c]  Optic  neuritis  occurs  in  80  per  cent,  of  all  cases,  and 
is  usually  bilateral.  The  old  name  of  "  choked  disk  "  given 
to  this  condition  is  inappropriate,  as  the  condition  is  due,  not 
to  pressure,  but  to  a  descending  neuritis.  Double  optic 
neuritis  occurs  with  lead-encephalopathy,  meningitis,  cerebral 
abscess,  anemia,  and  Bright's  disease,  but  an  intracranial 
tumor  is  by  far  its  most  frequent  cause.  In  the  first  stage 
the  disk  is  swollen,  its  edges  are  blurred  and  striated,  and 
the  physiological  cupping  disappears.  During  the  first 
stage  there  may  be  no  disturbances  of  vision,  but  dimness 
of  vision,  restricted  field  of  vision,  or  color-blindness  may 
be  noticed.  Atrophy  of  the  optic  nerve  usually  supervenes  ; 
the  disk  has  a  glassy,  white  appearance,  and  the  arteries 
are  small.  In  the  stages  of  atrophy  impairment  of  vision, 
or  even  total  blindness,  may  result.     Optic  neuritis,  while 


702        MAXL'AL    OF   THE   rRACTICE    OF  MEDICINE. 

not  a  localizing  symptom,  is  most  frequent  with  tumors  of 
the  cerebellum  and  of  the  basic  ganglia. 

(rt')  Voinitifig  occurs  in  50  per  cent,  of  the  cases,  and  is 
most  marked  with  cerebellar  tumor.  The  vomiting  is 
"  purposeless,"  has  no  relation  to  meals  or  to  local  causes, 
and  may  assume  a  projectile  character. 

{c)  Vertigo  is  present  in  20  per  cent,  of  the  cases,  and  is 
most  constant  and  severe  with  tumors  of  the  cerebellum. 
In  man)'  cases  vertigo  persists  while  the  patient  is  lying 
down,  so  that  he  will  hold  on  to  the  side  of  the  bed  in 
order  "  not  to  be  thrown  out."  In  other  cases  vertigo  is 
noticed  only  with  a  change  in  position. 

(/")  General  epileptiform  convulsions  may  occur,  and 
glycosuria  and  polyuria  have  been  noticed,  especially  with 
cerebellar  tumors. 

(^g)  T\iQ  pulse  is  usually  slower,  varying  between  50  and 
70.     The  boiuels  are  usually  constipated. 

2.  Localizing  Symptoms. — [ci)  Tumors  of  the  frontal  lobes 
give  rise  to  mental  dulness,  irritability,  and  dementia. 
There  may  be  loss  of  smell.  The  motor  area  may  finally 
be  encroached  upon. 

if?)  Tumors  of  the  motor  area  give  rise  at  first  to  mono- 
spasm ("  Jacksonian  epilepsy  "),  preceded  by  sensory  aurje. 
As  the  tumor  grows  the  spasms  become  more  diffused,  so 
that  by  considering  the  "  signal  symptom  "  and  the  march 
of  the  spasm  the  exact  location  and  rapidity  of  growth  may 
accurately  be  determined.  Monoplegia  succeeds  mono- 
spasm, the  lesion,  at  first  irritative,  later  becoming  destruc- 
tive. Lesions  extending  deeply  toward  the  capsule  may 
cause  hemispasm  and  hemiplegia.  The  paralyzed  muscles 
may,  to  a  moderate  degree,  be  insensitive  to  pain,  touch, 
and  temperature. 

if)  Tumors  of  the  parieto-occipital  lobe  may  give  rise  to 
no  localizing  symptoms.  Word -blindness  results  from 
lesions   of  the   left   angular   gyrus. 

{d^  Tumors  of  the  occipital  lobe  produce  hemianopia, 
and,  if  the  left  hemisphere  be  involved,  there  may  result 
word-blindness  and  mind-blindness.  The  latter  symptom, 
also  known  as  "  soul-blindness,"  consists  in  the  incapacity 


TUMORS   OF    'J'JIK   BRAIN.  703 

to  understand  the  nature  of  things  which  one  sees.  Bi- 
lateral lesions  may  produce  blindness. 

ie)  Tumors  of  the  temporal  lobe  on  the  left  side  may 
cause  word-deafness.  By  extension  the  motor  area  may  be 
involved. 

(/)  Tumors  of  the  basic  ganglia  give  rise  to  no  character- 
istic symptoms  unless  the  internal  capsule  is  involved  or 
the  lateral  ventricles  become  distended  by  pressure. 

(^)  Tumors  of  the  corpora  qiiadrigemina  produce  inco- 
ordination, forced  movements,  and  oculo-motor  paralysis. 

(//)  Tumors  of  the  cms  cause  opposite  hemiplegia  or 
hemianaesthesia,  with  paralysis  of  the  third  nerve  on  the 
same  side  as  the  lesion. 

(/)  Tumors  of  the  pons  are  chiefly  productive  of  paralysis 
of  the  nerves  emerging  from  this  region  on  the  same  side 
as  the  lesion,  with  opposite  hemiplegia  or  hemianaesthesia. 
Conjugate  deviation  of  the  eyes  away  from  the  side  of  the 
lesion  may  be  observed. 

(y)  Tumors  of  the  medulla  may  cause  paralysis  of  the 
cranial  nerves  alone,  with  the  symptoms  of  bulbar  paralysis  ; 
or  there  may  be  hemiplegia  or  convulsions. 

{Ji)  Tumors  of  the  cerebellum  present  distinct  peculiarities, 
especially  if  the  middle  lobe  be  involved.  The  symptoms 
consist  of  marked  occipital  headache  from  pressure  of  the 
tentorium ;  marked  vertigo,  especially  if  the  middle  lobe  be 
implicated ;  cerebellar  ataxia,  and  a  pitching  or  reeling  gait. 
Involvement  of  the  middle  lobe  causes  pitching  toward  the 
side  of  the  lesion,  forward  or  backward  according  to  whether 
the  anterior  or  posterior  portion  of  the  lobe  be  involved. 
Optic  neuritis  and  vomiting  occur  early  and  are  marked. 
The  pressure  of  the  growth  on  the  straight  sinus  causes  ve- 
nous congestion  and  distention  of  the  ventricles  with  serum 
(see  Fig.  62).  In  this  way  mental  slowness  and  general 
convulsions  may  be  developed.  Pressure  of  the  growth  on 
the  medulla  may  cause  bilateral  rigidity,  increased  reflexes, 
and  vaso-motor  symptoms  in  different  parts  of  the  body. 

The  diagnosis  of  brain-tumor  may  be  made  from  the 
general  symptoms  alone.  Strict  localization  is  often  pos- 
sible. 


704        MAXr.-lL    OF   THE   PRACTICE    OF  MEDIC  EVE. 

The  duration  varies  from  one  to  three  years.  In  rare 
cases  the  s\-mptoms  may  persist  for  a  longer  time  than  this. 

The  prognosis  is  bad,  except  for  gumma  and  operable 
erowths. 


Fig.  6=. — Diagram  showing  the  manner  in  which  compression  of  the  veins  of  Galen  is 
produced  by  a  tumor  of  the  cerebellum,  more  especially  of  its  middle  lobe  (after  Stephen 
Mackenzie).  The  letter  a  points  to  the  superior  and  l>  to  the  inferior  longitudinal  sinus, 
c  to  the  straight  sinus,  <i  to  a  tumor  beneath  the  tentorium,  and  e  to  the  veins  of  Galen. 

Treatment. — The  patient  should  be  given  mercurial  in- 
unctions, and  potassium  iodide  up  to  300  grains  daily. 
If  the  growth  be  gumma,  the  results  are  often  brilliant.  In 
tubercular  tumors  a  general  tonic  treatment  is  indicated,  as 
there  are  cases  reported  in  which  the  tubercular  tumors 
have  undergone  encapsulation  and  calcific  change,  and 
have  ceased  developing. 

The  surgical  treatment  consists  in  trephining  and  remov- 
ing the  tumor.  Brilliant  results  have  followed  this  pro- 
cedure in  cases  in  which  the  tumor  was  superficial,  accessi- 
ble, and  capable  of  enucleation.  The  actual  number,  how- 
ever, of  operable  cases  is  small  (less  than  5  per  cent, 
according  to  Dana).  In  case  of  doubt  an  exploratory 
trephining   is   advisable.    ' 

CEREBRAL    ATROPHY   IN    CHILDREN, 
Etiology. — Cerebral  atrophy  in  children  may  be  congen- 
ital, or  may  be  acquired  by  injuries  at  birth  or  by  such  dis- 
eases as  occur  in  adults.     In  343  cases  collated  by  Starr, 


CEREBKAL   ATROPI/Y  IN   C/ff/.nh' EN.  705 

the  following  primary  lesions  have  been  followed  by  atro- 
phy of  the  brain  in  children : 

PorencepJialiLS,  a  localized  atrophy  in  the  cerebral  hemi- 
sphere, which  may  be  deep  enough  to  open  into  a  ventricle 
— 132  cases. 

Sclerotic  atrophy,  atrophy  of  nerve-elements  with  increase 
of  connective  tissue,  involving  one  or  both  hemispheres,  or 
part  of  a  hemisphere,  or  in  small  scattered  areas — 97  cases. 

Maldevelopment — 32  cases. 

Atrophy  following  softening  produced  by  embolism  or 
thrombosis,  and  limited  to  arterial  districts  of  the  brain — 
23  cases. 

Meuingo-enccphalitis ,  shown  by  thickening  and  adhesion 
between  the  pia  and  the  brain,  with  atrophy  of  the  cortex — 
21  cases. 

Cysts  lying  on  the  brain,  causing  atrophy  by  pressure,  or 
associated  with  atrophy  due  to  the  original  disease  of  which 
the  cyst  remains  as  a  trace — 14  cases. 

Hemorrhage  on  or  in  the  brain — 18  cases. 

Hydrocephalus  with  thinning  of  the  brain-tissue — 5  cases. 

Unilateral  hydrocephalus — i  case. 

An  inflammation  of  the  cells  of  the  motor  cortex  anal- 
ogous to  anterior  poliomyelitis  has  been  described  by  Striim- 
pell,  but  lacks  positive  evidence. 

Symptoms. — Four  clinical  groups  may  be  described  : 

I.  Infantile  Hemiplegia. — The  attacks  are  usually  pre- 
ceded by  convulsions  and  fever  followed  by  unconscious- 
ness and  hemiplegia.  A  gradual  improvement  occurs 
up  to  a  certain  point,  after  which  the  symptoms  remain 
permanently.  The  paralysis  may  be  evident,  or  there 
may  only  be  stiffness  and  clumsiness  in  performing  volun- 
tary motions.  There  may  or  may  not  be  aphasia.  The 
paretic  muscles  show  lack  of  development  and  are  small 
and  cold.  Rigidity  is  due  to  a  condition  of  exaggerated 
reflexes.  The  electrical  reactions  are  unchanged.  Essential 
atrophy  of  the  muscles  does  not  occur.  The  affected  muscles 
may  show  tremor  or  inco-ordinate  choreiform  movements 
("  post-hemiplegic  chorea  "),  or  there  may  be  involuntary 
rhythmical  spasms  of  the  fingers  and  the  toes  ("  athetosis  "), 


706        M.IXI\1L    OF   THE    PKACJ'ICE    OF  MFDICIXE. 

Various  deformities,  such  as  club-foot,  arise  from  the  actiun 
of  the  unparalyzed  muscular  anta<^onists.  Epileptiform 
attacks  occur  in  one-half  the  cases.  The  patient  is  apt  to 
be  imbecile  or  feeble-minded. 

Infantile  hemiplegia  dating  from  birth  is  to  be  ascribed  to 
meningeal  hemorrhage  occurring  from  traumatism  during 
a  difficult   labor. 

2.  A  double  hemiplegia  due  to  meningeal  hemorrhage 
during  birth  is  described  as  spastic  diplegia  or  birtli- 
palsy.  More  rarely  the  condition  follows  fevers  or  convul- 
sions. The  extremities  are  paretic  and  rigid  from  over- 
reflexes.  The  mental  condition  is  defective,  and  convul- 
sions are  common.  The  muscles  act  irregularl)'  ("  chorea 
spastica  "),  or  there  may  be  bilateral  athetosis. 

3.  In  some  patients  mental  defects  constitute  the  principal 
symptoms.  In  these  cases  the  sclerotic  atrophy  involves 
the  anterior  portion  of  the  brain.  The  following  descrip- 
tion is  giv^en  by  Starr : 

"The  child  maybe  slow  in  learning  to  talk ;  may  seem 
unable  to  fix  its  attention  upon  anything  continuously;  may 
be  exceedingly  active,  in  constant  motion — the  activit}'  be- 
ing, however,  aimless ;  may  throw  things  about,  or  tear 
things  up,  or  put  everything  into  its  mouth  ;  may  be  very 
difficult  to  manage  because  of  its  inability  to  retain  and 
combine  impressions  with  sufficient  power  to  reason  upon 
them ;  and  may  therefore  be  incapable  of  appreciating  the 
meaning  of  punishment,  if  this  be  inflicted.  Such  children 
may  have  good  powers  of  perception,  may  recognize  per- 
sons and  objects,  show  pleasure  at  bright  colors  or  music 
or  caresses,  but  fail  to  show  evidence  of  thought  in  the 
sense  of  reasoning  power,  judgment,  or  self-control.  Some 
patients  constantly  drool  at  the  mouth,  cannot  be  taught 
cleanly  habits,  and  are  manifestly  imbecile.  Other  patients 
are  quite  bright  in  many  directions,  may  even  be  precocious, 
show  talents  in  music  or  drawing,  or  fondness  for  mathe- 
matics, designing,  or  languages,  yet  are  apparently  unable 
to  appreciate  moral  ideas,  cannot  be  taught  to  tell  the  truth, 
are  cruel  and  bad,  will  not  control  any  of  their  impulses, 
and  so  are  the  distress  and  despair  of  parents  and  teachers. 


CERKBRO-SP/NAJ.    SCLEROSIS.  "JOJ 

It  is  those  mental  qualities  which  arc  the  product  of  the 
highest  evolution  that  have  failed  to  develop  in  this  class 
of  cases.  The  final  result  is  that  they  have  to  be  taken  care 
of  all  their  lives,  either  at  home  or  by  attendants,  being  in- 
capable of  supporting  themselves  or  directing  their  conduct. 
Many  of  them  have  epilepsy." 

4.  In  a  fourth  set  of  cases  there  are  neither  moral  nor 
motor  defects,  but  the  patients  are  subject  to  epilepsy,  and 
they  present  defects  of  sensory  perception.  Many  cases  of 
deaf-mutism  belong  to  this  class.  In  these  patients  the 
atrophy  affects  the  temporal  and  occipital  convolutions. 

The  prognosis  is  bad  for  recovery,  although  life  may  not 
be  shortened. 

Treatment, — Prophylactic  treatment  consists  in  cutting 
short  all  convulsive  seizures  in  children — by  purgatives,  hot 
baths,  bromides,  chloral,  or  whiffs  of  chloroform. 

When  paralysis  occurs,  the  nutrition  of  the  muscles  is  to 
be  maintained  by  massage  and  passive  motion,  and  deformi- 
ties are  to  be  corrected  by  surgical  or  mechanical  measures. 
For  the  epileptic  attacks  bromides  may  be  found  useful.  In 
certain  cases  of  arrested  brain-development  due  to  micro- 
cephalic skull  the  result  of  premature  union  of  the  sutures, 
craniectomy  may  be  resorted  to.  When  clots,  cysts,  or 
tumors  are  removable  by  surgical  measures,  the  chance  of 
recovery  is  increased.  Epileptiform  convulsions  may  in  some 
cases  be  reduced  in  severity  and  in  frequency  by  removing  a 
portion  of  the  skull,  so  that  an  increase  in  the  intracranial 
pressure  can  occur  without  producing  pressure  on  the  brain. 

CEREBRO-SPINAL    SCLEROSIS. 

Etiolog-y  and  Synonyms. — The  etiology  of  cerebro- 
spinal sclerosis  is  obscure.  Heredity  is  marked  in  a  small 
number  of  cases.  The  disease  may  follow  any  of  the  infec- 
tious diseases,  especialh'  scarlet  fever.  It  is  most  common 
in  middle  life,  but  it  is  not  infrequently  seen  in  children. 
Syno)iyins :    Insular,   Multiple,    or    Disseminated    sclerosis. 

Pathology. — Throughout  the  brain  and  cord  are  small 
grayish  nodules  of  connective  tissue  which  destroy  the 
medullary  sheath  of  the  nerves,  but  leave  the  axis-cylinder 


/OS        J/.I.VI.IL    OJ-    THE    rKACTJCK    OF  MEDICIXE. 

unchanged.  The  cortex  is  not  usually  involved.  Sclerosis 
of  the  .spinal  cord  alone  is  of  great  rarity. 

Symptoms. — The  onset  is  insidious  and  is  marked  by 
feebleness  and  stiffness  of  the  legs  and  the  arms  and  by  in- 
creased reflexes.  The  feebleness  may  ultimately  develop 
into  paraK'sis,  so  that  the  patient  becomes  bedridden, 
^larked  tremor  is  developed  on  motion,  but  ceases  when  the 
muscles  are  at  rest.  The  speech  becomes  scanning  and 
"  syllabic."  Rapid  oscillation  of  the  eyeballs  (nystagmus) 
is  usualh'  pronounced.  The  association  of  volition-tremor 
with  scanning  speech  and  nystagmus  forms  a  characteristic 
symptom-group.  The  mental  state  usually  becomes  pro- 
gressively enfeebled.  Optic  neuritis  may  develop.  Sensa- 
tion is  usually  unaffected,  but  there  may  be  lightning  pains 
and  anaesthetic  areas  as  in  locomotor  ataxia.  Vertigo  is 
common.  There  may  be  apoplectic  seizures,  with  coma, 
fever,  and  transient  hemiplegia,  or  there  may  be  epileptiform 
convulsions.  The  patient  finally  becomes  unable  to  per- 
form the  ordinary  duties  of  life,  by  reason  of  mental  weak- 
ness, volitional  tremor,  and  muscular  feebleness.  The  course 
of  the  disease  is  chronic,  with  periods  of  temporary  improve- 
ment. 

Diagnosis. — The  disease  may  resemble  h)'S>teria  or  Fried- 
reich's ataxia  in  children.  Anomalous  cases  are  occasionally 
encountered,  which  resemble  transverse  myelitis,  locomotor 
ataxia,  or  general  paresis. 

The  prognosis  for  recovery  is  bad. 

Treatment  is  practically  unavailing.  A  course  of  mer- 
cury bichloride  with  potassium  iodide  may  be  tried  in  alter- 
nation with  small  doses  (gr.  -^  )  of  nitrate  of  silver.  In  all 
cases  a  quiet  life  is  to  be  advised. 

GENERAL    PARESIS. 

Etiology  and  Synonyms. — The  disease  is  common  be- 
tween the  ages  of  thirty  and  fifty-five,  and  is  more  frequent 
in  men  than  in  women.  Heredity  appears  in  15  per  cent,  of 
the  cases.  The  exciting  cause  may  be  prolonged  mental 
strain,  excesses,  syphilis,  alcoholism,  and  lead-poisoning. 
The    disease    is   not    uncommon  among    active,   ambitious 


GENERAL    PARESIS.  7O9 

business-men.  S)nio)iyms  :  Paretic  dementia  ;  General  paral- 
ysis of  the  insane;  Chronic  meningo-encephalitis  ;  Chronic 
periencephalitis. 

Pathology. — The  membranes  are  thickened,  opaque,  and 
adherent  in  places  to  the  brain-substance  ;  the  cortex  is  firm 
and  more  or  less  atrophied ;  there  is  an  increase  in  the 
cerebro-spinal  fluid.  Microscopic  examination  shows  an 
increase  of  connective  tissue,  with  a  degeneration  and  dis- 
appearance of  nerve-fibres  and  ganglionic  cells.  In  the  cord 
similar  sclerotic  areas  are  found  in  the  posterior  and  lateral 
columns.  The  ventricles  are  usually  dilated.  There  may 
be  small  areas  of  softening  in  the  brain-substance,  associated 
with  arterial  sclerosis. 

The  symptoms  begin  insidiously  with  a  change  in  the 
moral  nature.  The  patient  becomes  inattentive  and  forget- 
ful, and  may  violate  the  ordinary  rules  of  decency  and 
deportment.  There  is  increasing  mental  weakness,  with 
irritability  of  temper.  A  peculiar  egotism  usually  but  not 
invariably  develops,  with  delusions  of  grandeur,  so  that  the 
patient  becomes  absurdly  boastful,  and  believes  himself  to 
be  possessed  of  millions  of  money,  or  to  have  made  the 
most  wonderful  inventions,  or  to  be  king,  emperor,  or  even 
God  himself  Vaso-motor  phenomena  and  general  neuras- 
thenia add  their  symptoms.  In  the  earlier  stages  motor 
symptoms  may  be  noticed  :  the  tongue  trembles  when  it  is 
protruded  ;  the  gait  is  unsteady  and  shuffling.  The  pupils 
are  frequently  unequal.  They  may  react  to  distance,  but 
not  to  light  ("  Argyll-Robertson  pupil  ").  There  may  be 
epileptiform  seizures  or  Jacksonian  epilepsy,  frequently  fol- 
lowed by  transient  paralyses.  The  speech  becomes  thick, 
owing  to  the  difficulty  of  pronouncing  the  lingual  and 
labial  consonants.  Scanning  or  a  slow,  hesitating,  monoto- 
nous speech  is  common,  words  and  syllables  are  frequently 
omitted,  and  the  patient  stumbles  over  words.  Writing 
becomes  uncertain  and  irregular,  and  letters  or  words  may 
be  omitted ;  finally  the  writing  becomes  totally  illegible. 
The  gait  becomes  increasingly  impaired,  and  may  be  spastic 
or  ataxic.  The  knee-jerk  is  usually  increased.  ?klaniacal 
outbursts  may  follow  the  delusions  of  grandeur,  or  there 


710        M.IXLAL    OF   THE   PRACTICE    OF  MEDIC  EVE. 

ma)'  be  periods  of  melancholia  or  of  depression.  In  the 
last  stages  the  patient  becomes  demented,  the  bladder  and 
rectum  become  unretentive,  the  health  fails,  and  the  patient 
becomes  bedridden.  Death  results  from  exhaustion  or  from 
intercurrent  disease. 

The  course  of  the  disease  is  progressive,  with  periods  of 
temporary  improvement.  The  average  duration  is  from 
three  to  four  years. 

The  prognosis  is  unfavorable. 

Treatment. — In  syphilitic  cases  a  thorough  course  of 
iodide  and  mercurials  should  be  employed,  but  not  much  is 
to  be  expected  from  the  treatment.  Nursing  and  a  quiet 
life  in  an  asylum  really  constitute  the  only  treatment  of  the 
disease. 

CHRONIC  HYDROCEPHALUS. 

An  increase  in  the  amount  of  fluid  in  the  ventricles 
occurs  in  a  congenital  and  an  acquired  form. 

Congenital  Hydrocephalus. — No  known  cause  has 
been  discovered  for  this  condition.  It  has  occurred  in 
several  members  of  the  same  family.  The  lateral  ventricles 
are  principally  affected,  and  are  distended  with  fluid,  so  that 
the  cerebral  cortex  over  them  is  thin  and  stretched  and 
may  be  converted  to  a  thin  shell  less  than  a  quarter  of  an 
inch  in  thickness.  The  sutures  and  fontanelles  are  widely 
distended,  so  that  the  skull  becomes  enormously  enlarged, 
in  some  cases  exceeding  thirty  to  thirty-two  inches  in 
diameter  for  a  child  of  two  or  three  years.  The  bones  of 
the  cranium  are  thinned,  the  orbital  plates  are  so  depressed 
as  to  cause  exophthalmos.  The  fluid  is  limpid,  contains 
traces  of  albumin  and  salts,  and  sometimes  contains  urea. 

Symptoms. — The  head  may  be  so  large  at  birth  as  to 
interfere  with  natural  labor.  In  other  cases  the  head  does 
not  increase  in  size  until  several  weeks  after  birth.  The 
child  is  restless  and  irritable.  There  is  difficulty  in  getting 
the  child  to  walk,  or  the  legs  may  be  feeble  and  in  a  con- 
dition of  exaggerated  reflexes.  A  few  children  are  bright, 
but  in  the  great  majority  some  grade  of  imbecility  is 
present.     Strabismus  and  optic  atrophy  may  develop  ;  nys- 


SYPHILIS   OF   IIIK    BKAIN.  /If 

tagmus  is  commonly  present.  Vomiting,  coma,  and  con- 
vulsions ultimately  appear,  and  the  child  rarely  lives  for 
more  than  three  or  four  years. 

Acquired  Chronic  Hydrocephalu.s.  —  This  condition 
may  result  from  compression  or  obliteration  of  the  straight 
sinus  or  of  the  passage  from  the  third  to  the  fourth  ventricle 
by  a  tumor  ;  other  cases  follow  meningitis.  In  a  few  in- 
stances the  condition  arises  without  known  cause  ("  serous 
apoplexy  "). 

The  symptoms  are  obscure,  and  a  diagnosis  during  life 
is  but  seldom  made.  Headache,  optic  neuritis  proceeding 
to  atrophy,  and  attacks  of  stupor  are  commonly  observed. 
The  head  in  the  acquired  form  does  not  enlarge.  There 
are  no  localizing  symptoms. 

Treatment  of  Hydrocephalus. — Gradual  compression 
of  the  skull  should  be  made  by  straps  of  adhesive  plaster 
crossed  in  various  ways.  When  pressure-symptoms  are 
present,  puncture  of  the  ventricles  by  a  fine  aspirating 
needle  and  the  withdrawal  of  small  quantities  of  fluid  from 
time  to  time  are  justifiable  procedures.  The  subarachnoid 
sac  between  the  third  and  fourth  lumbar  vertebrae  may  be 
punctured  without  risk  of  injury  to  the  cord,  and  the  fluid 
slowly  removed  without  much  danger  of  collapse.  Med- 
icines are  useless,  although  inunctions  of  mercury  and  the 
administration  of  potassium  iodide  have  been  recommended. 

SYPHILIS  OP  THE  BRAIN. 

Congenital  syphilis  of  the  brain  may  develop  during 
earl}^  childhood,  but  it  is  rare.  The  acquired  form  is 
usually  a  late  tertiary  manifestation  of  the  disease,  although 
it  may  develop  in  from  six  months  to  thirty  years  after  the 
primary  sore.  The  earlier  occurrence  of  symptoms  is  by 
some  authors  attributed  to  the  appearance  upon  the  mem- 
branes of  an  actual  syphilitic  eruption  analogous  to  the 
cutaneous   exanthems   of  the   secondary  period. 

I.  Syphilis  of  the  Bones  of  the  Cranium. — The  lesion  con- 
sists in  the  formation  of  spots  of  dry  caries,  nodes,  and 
necrosis.  Cerebral  symptoms  arise  only  if  the  membranes 
be  secondarily  inflamed.    If  the  lesions  involve  the  foramina 


712        M.IXLA/.    OF   THE    PRACTICK    OF  MEDIC IXE. 

tliroLigh  which  the  cranial  nerves  pass,  there  will  be 
developed  neuralgic  pains  or  motor  spasms,  followed  by 
ancEsthesia  or  paralysis. 

2.  Syphilitic  Meningitis.  —  The  meinbrancs  show  the 
lesions  of  an  acute  or  chronic  inflammation,  and  are  invaded 
b\-  gummata.  The  symptoms  arc  those  of  the  meningitis 
and  those  of  the  multiple  tumors  pressing  on  the  cortex, 
and  according  to  the  predominance  of  either  group  of 
symptoms  the  case  will  resemble  acute  or  chronic  menin- 
gitis or  cortical  tumors.  The  suggestive  points  of  s)'philitic 
meningitis  are — (i)  Headache,  existing  several  weeks  before 
the  onset  of  other  symptoms,  severe  in  character,  and  worse 
at  night,  preventing  sleep ;  (2)  the  admixture  of  symptoms 
of  inflammation  of  the  meninges  and  of  cortical  tumors;  (3) 
the  rapid  improvement  under  treatment. 

3.  Gummata  of  the  Brain. — The  symptoms  of  brain- 
tumor  are  frequently  preceded  by  intense  nocturnal  head- 
ache, by  temporary  incomplete  paraK'sis  of  an  arm  or  a  leg, 
or  by  temporary  squint.  These  partial  passing  palsies  are 
quite  suggestive  of  cerebral  syphilis.  The  general  and 
localizing  symptoms  of  cerebral  gummata  have  been  dis- 
cussed under  the  heading  of  Tumors  of  the  Brain. 

4.  Syphilitic  Endarteritis. — The  syphilitic  changes  in  the 
walls  of  the  cerebral  arteries  were  described  by  Huebner  in 
1874,  and  the  lesion  is  known  as  "  Huebner's  arteries." 
The  lesion  consists  in  a  thickening  of  the  intima  by  con- 
nective tissue,  in  some  cases  leading  even  to  an  obliteration 
of  the  lumen.  Areas  of  softening  may  occur  in  the  brain- 
tissue,  from  the  obliteration  of  the  lumen  of  the  vessel  by 
this  new  growth  or  by  thrombus-formation.  The  middle 
cerebral  artery  is  the  one  most  usually  and  most  exten- 
sively affected.  The  symptoms  resemble  those  of  cere- 
bral endarteritis.  Syphilitic  stupor  and  paralysis  require 
special  description. 

Syphilitic  Stupor. — The  patient  complains  of  severe  noc- 
turnal headache,  and  after  a  time  passes  into  a  peculiar 
somnolent  condition ;  he  may  lie  for  days  apparently  asleep, 
or  may  sit  for  hours  at  a  time  in  a  torpid,  dazed  state  of 
mind,  answering  questions   in   a  peculiar,   slow,  automatic 


SYPHILIS    OF    HIE   BRAIN.  713 

way,  as  though  talking  in  his  sleep.  From  time  to  time 
the  patient  may  wander  about  in  an  aimless  fashion.  The 
evidences  of  severe  headache  are  usually  marked,  even 
during  the  periods  of  stupor.  Prolonged  stupor  is  of  seri- 
ous import,  but  is  not  incompatible  with  complete  recovery. 
The  majority  of  cases,  unless  relieved  by  treatment,  sud- 
dently  pass  into  a  condition  of  profound  coma,  which  is 
usually  fatal. 

Syphilitic  paralysis  comes  on  suddenly,  without  loss  of 
consciousness  and  without  exciting  cause.  The  paralysis, 
which  is  not  complete,  and  is  of  a  transitory,  fugitive  charac- 
ter, may  be  of  irregular  distribution  or  may  be  hemiplegic 
in  type.  Oculo-motor  paralysis  is  not  uncommon.  These 
fugitive  palsies  are  due  to  functional  brain-disturbance  from 
the  diminished  blood-supply  through  the  narrower  arteries. 
Should  thrombus  occur,  softening  will  ensue,  so  that  the 
paralysis  becomes  permanent. 

5.  Syphilitic  disease  of  the  brain  may  present  nearly  the 
clinical  picture  of  general  paresis.  The  exact  pathology 
of  these  cases,  however,  is  not  known,  and  it  cannot  be 
asserted  as  yet  that  this  form  of  syphilitic  brain  disease  is 
an  independent  affection. 

The  prognosis  is,  upon  the  whole,  favorable,  although  it 
should  be  guarded.  More  or  less  recovery  is  to  be  expected 
unless  the  symptoms  indicate  an  absolute  destruction  of 
brain-tissue. 

Treatment  consist  in  the  vigorous  employment  of  anti- 
syphilitic  drugs.  Mercury  should  at  once  be  ordered  by 
inunction,  and  pushed  until  the  "  gums  are  touched."  Sali- 
vation, however,  should  always  be  avoided. 

Potassium  iodide  in  30-grain  doses  three  times  a  day, 
largely  diluted  in  water  or  milk,  should  be  pushed  rapidly 
until  300  grains  daily  are  taken,  unless  the  patient  show 
such  dangerous  symptoms  of  iodism  as  hemorrhages.  In 
cases  of  sudden  coma  timely  venesection  may  be  the  means 
of  savine  life. 


714        ^^/.l.vr.lL    OF   THE   PRACTICE    OF  MEDICEXE. 

4.  DISEASES  OF  THE  SPINAL  CORD, 

[ii)  Affections  of  tuk  Meninges. 

DISEASES    OP    THE    DURA    MATER. 

PACHVMENiNciiTis  EXTERNA  occui's  ill  ail  acutc  aiid  in  a 
chronic  form.  The  acute  cases  regularly  are  secondary  to 
intlainniation  of  the  vertebral  bones  or  to  the  extension  of 
neighboring  abscesses.  The  inflammation  is  fibrino-purulcnt 
and  gives  the  symptoms  of  a  compression-myelitis. 

Chronic  external  pachymeningitis  is  usually  due  to 
tubercular  disease  of  the  vertebrae.  The  external  layer  of 
the  dura  is  rough,  thickened,  and  covered  with  cheesy 
material. 

The  symptoms  are  due  to  irritation  and  compression  of 
the  anterior  and  posterior  nerve-roots  (hj'perassthesia  and 
motor  spasms,  anaesthesia,  paralysis,  atrophy  of  muscles,  and 
loss  of  reflexes)  and  to  slow  compression  of  the  spinal  cord 
(loss  of  motion  and  sensation  below  the  lesion). 

Treatment  is  that  of  the  original  disease  and  that  of 
myelitis. 

Pachymeningitis  Interna  H.emorrhagica  (Hcnematoma 
of  the  Dura  Mater). — This  disease  is  usually  associated  with 
a  similar  affection  of  the  dura  mater  of  the  brain,  and  the 
two  lesions  are  identical,  so  that  a  further  description  of  the 
disease  process  is  not  necessary.  The  cervical  region  is  the 
one  usually  affected.  The  symptom?  arc  those  of  chronic 
spinal  meningitis — pain  in  the  back,  motor  and  sensory  irri- 
tation and  impairment.  Hemorrhages  occur  from  time  to 
time,  causing  sudden  exacerbations  of  the  spinal  .symptoms 
and  compression-.symptoms  (see  Meningeal  Hemorrhage). 

Treatment  is  unavailing. 

P.A.CHVMENINGIT1S    INTERNA     HvPERTROPHICA. The     dura 

becomes  thickened  by  fibrous  tissue,  which  irritates  and  de- 
stroys the  nerve-roots  and  causes  slow  compression  of  the 
cord.  The  thickening  of  the  dura  generally  extends  above 
the  cord  like  a  ring,  and  is  usually  limited  to  the  cervical 
resfion. 


DISEASES   OF   77/E   J' J. I    MATER.  715 

Symptoms. —  i.  Stage  of  Irritation. — The  symptoms  are 
due  to  irritation  of  the  anterior  and  posterior  nerve-roots. 
Neuralgic  pains  develop  in  the  course  of  the  affected  nerves, 
and  are  referred  to  the  neck,  arms,  and  the  upper  portion  of 
the  thorax.  There  are  areas  of  hyperaesthesia  with  tingling 
sensations.  Motor  symptoms  consist  of  spasm  and  rigidity 
of  the  neck  and  of  the  muscles  of  the  upper  extremities. 

2.  Stage  of  Destruction. — Hyperaesthesia  and  neuralgia 
give  way  to  anaesthesia.  Paralysis  with  atrophy  and  loss 
of  reflex  succeeds  the  muscular  spasms.  Deformities  result 
from  the  atrophy  and  paralysis.  If  the  lower  cervical  en- 
largement be  compressed,  the  ulnar  and  median  nerves  are 
chiefly  affected,  so  that  over-e.xtension  of  tl\e  hand  results. 
If  the  lesion  be  higher  up,  the  musculo-spiral  nerve  is 
affected,  so  that  the  hand  will  drop.  Secondary  degenera- 
tion of  the  pyramidal  tract  results  from  the  pressure-myelitis, 
and  spastic  paraplegia  develops  (see  Secondary  Lateral 
Sclerosis). 

The  prog-nosis  is  bad  for  recovery,  although  death  usually 
results  from  intercurrent  disease.  In  some  cases  the  dis- 
ease may  be  arrested,  and  the  patient  live  for  years  with 
permanent  contractures  and  deformities. 

Treatment  consists  of  counter-irritation  to  the  affected 
portion  of  the  spine,  and  the  empirical  use  of  potassium 
iodide. 

DISEASES    OF    THE   PIA  MATER. 

Acute  Leptomeningitis. 
Etiology. — Acute  inflammation  of  the  pia  covering  the 
cord  may  be  due  to  extension  of  a  similar  inflammation  of 
the  pia  of  the  brain,  being  thus  part  of  the  lesion  of  a  simple 
or  an  epidemic  meningitis  ;  or  it  may  be  due  to  traumatism 
of  the  vertebrae,  or  to  operation,  such  as  the  opening  of  a 
spina  bifida.  The  disease  may  complicate  certain  acute 
infectious  diseases,  especially  pneumonia,  small-pox,  scarlet 
fever,  and  typhoid  fever.  A  tubercular  inflammation  of  the 
spinal  meninges  may  also  occur.  In  a  few  cases  the  excit- 
ing cause  seems  to  be  exposure  to  wet  and  cold.  The  in- 
fecting germ  may  be  that  of  epidemic  cerebro-spinal  men- 


7l6        .VJ.Vr.-1L    OF  THE    PK.ICIVCE    OF  MEDICI.XE. 

ingitis  {(J.  7'.),  the  cocci  of  pus,  the  pncumococcus,  or 
Eberth's  bacillus. 

Patholog'y. — The  lesions  may  be  diffused  throughout  the 
length  of  the  cord  or  may  be  localized  in  the  cervical  region. 
The  pia  is  congested,  thickened,  and  infiltrated  with  fibrin, 
serum,  and  pus.  The  exudation  is  usually  more  abundant 
in  the  posterior  portions  of  the  pia,  owing  to  gravitation 
when  the  patient  lies  upon  his  back.  The  peripheral  por- 
tions of  the  cord  are  usually  infiltrated  by  inflammatory 
products.  The  nerve-roots  may  also  be  involved.  In  the 
majority  of  cases  similar  lesions  are  found  in  the  cerebral 
pia  mater. 

The  symptoms  are  due  in  the  first  stage  to  intense  irrita- 
tion of  the  spinal  nerves.  Pain  in  the  back  and  shooting 
pains  along  the  nerves,  with  areas  of  hyperassthesia,  are  the 
prominent  sensory  s\-mptoms.  Irritation  of  the  motor  ncrx'cs 
gives  rise  to  spasm  and  rigidity  of  the  affected  muscles. 
The  spine  is  stiff  and  rigid  ;  the  head  is  thrown  back;  there 
may  be  opisthotonos.  Owing  to  the  retraction  of  the  head 
and  neck,  the  larynx  may  be  so  firmly  pressed  against  the 
spinal  column  as  to  cause  obstructive  dyspnoea  with  stridor. 
The  reflexes  are  generally  exaggerated.  There  may  be  reten- 
tion of  urine  from  reflex  spasm  of  the  bladder.  During  the 
earlier  stages  there  is  no  paralysis,  though  the  muscles  may  be 
kept  quiet,  so  as  not  to  increase  the  neuralgic  pains.  Fever  is 
regularly  present,  but  runs  an  atypical  course,  rarely  ex- 
ceeding 104°  F.  Finally  the  second  stage  develops,  in 
which  hyperaesthesia  is  succeeded  by  anaesthesia,  the  pains 
cease,  and  complete  paralysis  supervenes.  There  may  now^ 
be  developed  bed-sores  and  paralysis  of  the  sphincters. 
Reflex  irritability  becomes  lost. 

The  diagnosis  ma\^  be  difficult.  Symptoms  of  spinal 
meningitis  may  be  present  in  cases  in  which  the  meninges 
are  afterward  demonstrated  to  be  normal,  while  well-marked 
cases  of  leptomeningitis,  especially  of  the  cerebro-spinal 
form,  may  be  unattended  by  characteristic  symptoms.  The 
diagnosis  from  tetanus  is  made  by  the  absence  of  trismus 
and  of  the  risus  sardonicus  and  by  the  intensity  of  the  pains. 
Myelitis   is  to  be  excluded  b\'  the  marked  and  continued 


DISEASES    OF   THE    EI  A    MATER.  JIJ 

hyperaesthesia,  by  the  late  appearance  of  paralysis,  and  by 
the  bladder  not  being  involved. 

The  prognosis  is  not  good,  although  the  acute  condition 
may  subside  and  symptoms  of  chronic  meningitis  develop. 
Dyspnoea  the  result  of  spasm  or  paralysis  of  the  re- 
spiratory muscles  is  a  most  unfavorable  symptom. 

The  treatment  is  practically  that  of  acute  myelitis. 

Chronic  Leptomeningitis. 

Etiology. — Chronic  spinal  meningitis  may  follow  an  acute 
attack  or  may  be  chronic  from  the  start.  In  the  latter  case 
the  disease  may  be  due  to  syphilis  or  alcoholism,  or  the 
lesion  may  complicate  chronic  diseases  of  the  cord  that  ex- 
tend so  as  to  involve  the  membranes,  or  extra-medullary 
lesions,  such  as  tumors  or  disease  of  the  vertebral  bones. 

Pathology. — When  the  condition  follows  an  acute  attack, 
the  lesions  usually  involve  an  extensive  area  of  the  mem- 
branes; in  other  cases,  chronic  from  the  start,  the  distribu- 
tion is  more  limited.  The  pia  is  thickened  and  adherent  to 
the  cord  and  the  dura.  The  nerve-roots  may  be  compressed, 
and  may  even  become  atrophied.  The  cord  usually  shows 
increase  of  connective  tissue  in  the  cortical  zones. 

The  symptoms  resemble  in  kind  those  of  the  acute  form, 
and  are  due  to  the  involvement  of  the  nerve-roots,  but  mus- 
cular spasms  are  much  less  prominent.  There  is  pain  in 
the  back,  radiating  along  the  course  of  the  nerves,  with 
areas  of  hyperaesthesia.  Stiffness  of  the  back  and  generally 
increased  reflexes  are  present  in  the  earlier  stages.  The 
rectum  and  the  bladder  are  but  seldom  involved.  Motor 
weakness  gradually  merges  into  paralysis,  with  atrophy  of 
the  muscles  and  loss  of  reflexes.  These  symptoms  result 
from  atrophy  of  the  anterior  nerve-roots  through  compres- 
sion by  the  thickened  pia.  The  symptoms  of  meningitis  are 
frequently  accompanied  by  those  due  to  a  primary  disease 
in  or  outside  of  the  spinal  cord. 

Prognosis. — The  disease  is  chronic  in  its  course,  extend- 
ing over  years.     Recovery  cannot  be  expected. 

Treatment  is  that  of  the  chronic  stage  of  myelitis. 


71 8      maxcal  of  the  practice  of  mediclxe. 

Hemorrhage  into  the  Spinal  Membranes. 

Etiology  and  Synonyms. — This  rare  condition  may  re- 
sult from  (i)  blows  and  concussions,  (2)  chronic  pach\'menin- 
gitis  hiL-morrhagica,  (3)  rupture  of  an  aortic  aneurysm  into 
the  spinal  column  after  erosion  of  the  vertebral  bones,  (4) 
hemorrhagic  diseases,  as  purpura  ha:morrhagica,  and  scurvy, 
(5)  after  convulsions  or  tetanus,  (6)  or  as  a  lesion  of  caisson- 
disease.  Blood  effused  into  the  cranium,  as  in  hemorrhages 
at  the  base,  may  make  its  way  down  between  the  membranes 
of  the  cord.  This  latter  diffusion  of  blood  occurs  most 
commonly  with  rupture  of  an  aneurysm  of  the  vertebral  or 
basilar  artery.  Synonyms :  Extra-medullary  hemorrhage; 
Ha^matorrhachis  ;  Spinal  apoplex)'. 

Pathology. — The  blood  may  be  found  between  the  dura 
and  the  bones  (extra-meningeal  hemorrhage),  and  is  extrav- 
asated  from  the  large  plexus  of  veins  h'ing  outside  the  dura. 
In  other  cases  the  blood  is  found  between  the  membranes 
(intra-meningeal  hemorrhage).  Hemorrhage  is  most  com- 
mon in  the  cervical  region,  but  it  ma\'  occur  anywhere.  In 
extensive  extravasations  the  spinal  cord  may  be  com- 
pressed, but  the  amount  of  blood  is  rarely  sufficient  for  this. 

Symptoms. — The  characteristic  features  of  hemorrhage 
within  the  spinal  membranes  are  the  sudden  appearance  of 
symptoms  of  an  intense  meningeal  irritation  without  initial 
fever.  Pain  develops  suddenly  in  the  back  and  radiates 
along  the  course  of  the  nerves.  There  are  muscular  rigidity 
and  spasm.  Motor  and  sensory  impairment  may  ultimately 
appear,  but  seldom  to  a  great  extent.  If  the  hemorrhage 
be  in  the  cervical  region,  the  pain  is  felt  in  the  arms,  the 
neck  is  rigid  and  immobile,  and  dysphagia,  interference 
with  respiration,  and  dilatation  of  the  pupils  may  appear. 
Larger  hemorrhages  in  the  upper  cervical  region  may  be 
immediately  fatal.  Occurring  in  the  dorsal  region,  the  pain 
encircles  the  abdomen.  Hemorrhage  in  the  lumbar  region 
causes  pain  in  the  legs ;  there  may  be  spasmodic  retention 
of  urine.  If  the  hemorrhage  compress  the  cord,  compres- 
sion-myelitis will  result,  with  paraplegia  and  anaesthesia,  and 
the  rectum  and  bladder  will  be  involved. 


IIEMORRHAGR   INTO    THE    CORD.  719 

The  prognosis  is  bad,  but  not  hopeless.  Perfect  recovery 
may  follow  slight  extravasations. 

Treatment. — The  patient  should  lie  on  the  face  while 
ice-bags  are  applied  to  the  spine.  Ergot  may  be  given  at 
the  onset  in  full  doses.  After  the  hemorrhage  has  ceased 
the  treatment  is  that  of  myelitis. 

[b)  Diseases  of  the  Blood-vessels. 

ANEMIA. 
The  etiology  and  symptomatology  of  spinal  anaemia  are 
but  little  known.  In  profound  anzemia  there  may  be  no 
symptoms  referable  to  the  cord.  It  is  known  that  ligature 
of  the  abdominal  aorta  in  animals  is  followed  by  paraplegia, 
and  in  man  this  paralytic  condition  has  followed  sudden 
blockage  of  an  aneurysm  of  the  abdominal  aorta  by  a 
thrombus  or  by  a  detached  portion  of  the  clot.  A  transient 
paraplegia  has  also  followed  sudden  and  profuse  hemorrhage 
or  exhausting  diarrhoea.  The  weakness  of  the  legs  in  those 
suffering  from  aortic  regurgitation  is  supposed  to  be  due  to 
spinal  anaemia. 

HYPEREMIA. 

Acute  hypercsmia  results  from  sexual  excesses,  physical 
over-exertion,  sudden  cessation  of  the  menses,  and  from 
over-dosing  by  strychnine. 

The  symptoms  are  indefinite.  There  may  be  numbness, 
with  neuralgic  pains,  muscular  twitching,  and  weakness, 
these  being  usually  confined  to  the  lower  extremities. 

Treatment  consists  in  the  application  of  an  ice-bag  or  of 
cups  to  the  spine.  The  patient  should  lie  on  the  side  or  the 
face.  Sodium  bromide  may  be  given  to  control  the  symp- 
toms. Ergot,  although  recommended  by  some,  does  not 
seem  to  be  of  as  much  service    as  is  generally  supposed. 

CJironic  JiypcrcBinia  may  complicate  various  lesions  of  the 
cord  and  membranes,  but  the  symptomatology  is  obscure. 

HEMORRHAGE    INTO    THE    CORD. 
Etiolog-y  and  Synonyms. — Hemorrhage  into   the  cord 
has    been    found   with    tetanus,   str\xhnine-poisoning,    and 


720        MA.yr.lL    OF   THE   PKACT/C/-:    OF  MEDICIXE. 

conditions  leadins^  to  sudden  asphyxia.  Hemorrhage 
commonly  comphcates  inflammations  and  tumors  of  the 
cord.  Primarx-  hemorrhage,  which  may  be  due  to  blows 
or  falls,  to  convulsions,  or  to  hemorrhagic  conditions,  is 
most  common  in  young  males.  S)')iofi)>)ns :  Ha.'mato- 
myelia  ;   Intramedullary  hemorrhage;  Spinal  apoplex}-. 

Pathology. — The  clot  is  rarely  larger  than  an  almond, 
and  is  usually  situated  in  the  central  gray  matter.  The 
nerve-structures  are  lacerated  at  the  seat  of  hemorrhage,  re- 
sulting in  a  total  transverse  destructive  lesion  of  the  cord. 

The  symptoms  resemble  those  of  acute  transverse  mye- 
litis, but  there  is  no  initial  fever,  the  paraplegia  is  suddenly 
induced,  and  the  stage  of  irritation  is  not  marked.  The 
case  may  resemble  one  of  spinal  meningeal  hemorrhage,  but 
in  the  latter  condition  pains  and  spasm  are  more  marked 
than  anaesthesia  and  paraplegia,  and  there  is  more  liability 
of  recovery. 

The  ultimate  course  of  spinal  hemorrhage  is  that  of  a 
chronic  transverse  myelitis,  and  in  many  cases  it  is  impos- 
sible to  say  whether  the  case  is  one  of  primary  hemorrhage 
with  myelitis  or  of  myelitis  with  secondary  hemorrhage. 

The  prognosis  is  not  good.  Many  cases  die  during  the 
acute  symptoms,  while  others  live  for  years  with  permanent 
paraplegia.  In  these  cases  the  prognosis  is  that  of  chronic 
myelitis. 

The  treatment  is  that  of  myelitis. 

Embolism  and  thrombosis  are  rare  conditions.  Em- 
bolism may  be  suspected,  should  a  patient  with  valvular 
disease  suddenly  develop  paraplegia  and  paranaesthesia  with- 
out other  apparent  cause. 

CAISSON-DISEASE;  DIVER'S  PARALYSIS. 
Etiology. — Persons  who  work  in  caissons  and  diving- 
bells  under  an  increased  atmospheric  pressure  may  develop 
this  disease  when  they  suddenly  emerge  into  the  normal 
atmosphere.  The  pressure  mu.st  be  more  than  three  atmo- 
spheres, and  the  longer  they  work  in  the  caisson  and  the 
more  suddenly  they  return  to  the  surface,  the  greater  is  the 


CAISSON-DISEASE;    DIVER' S  PARALYSIS.  72 1 

liability  to  the  disease.  Those  unused  to  the  work  are  most 
frequently  attacked. 

The  pathology  is  somewhat  obscure.  Under  raised 
atmospheric  pressure  the  blood  is  driven  from  the  surface 
to  the  internal  organs.  When  the  pressure  is  reduced  to 
the  normal,  vascular  disturbances  are  supposed  to  result  in 
the  cord,  with  spots  of  congestion  and  small  hemorrhages 
which  may  ultimately  result  in  myelitis.  Another  theory 
is  that  an  excess  of  nitrogen  is  absorbed  by  the  blood  when 
under  high  pressure,  and  that  when  the  pressure  is  too  sud- 
denly reduced  bubbles  of  this  gas  are  liberated  and  lacerate 
the  nerve-structures  of  the  cord. 

The  symptoms  may  appear  at  once  or  may  be  deferred 
half  an  hour  or  more  after  leaving  the  caisson.  In  most 
cases  there  are  agonizing  neuralgic  pains  in  the  limbs,  the 
legs  are  tender  to  the  touch,  and  there  is  some  loss  of 
motor  power.  There  are  apt  to  be  epigastric  pain,  nausea, 
vomiting,  headache,  and  dizziness.  In  severe  cases  paralysis 
and  anaesthesia  rapidly  develop  in  the  legs,  although  neur- 
algic pains  may  still  continue.  There  may  be  temporary 
loss  of  consciousness. 

Prognosis. — The  patient  may  convalesce  in  a  few  days, 
or  recovery  may  result  only  after  weeks  or  months  of  suf- 
fering and  paralysis.  Severe  cases  may  pass  into  coma, 
and  die  in  a  few  hours  or  days  after  the  onset.  Atrophic 
bed-sores  and  cystitis  may  complicate  the  course  of  the 
protracted  cases.  In  some  instances  the  patient  is  left 
with  permanent  paraplegia  and  the  symptoms  of  transverse 
myelitis. 

Treatment. — A  sufficient  time  must  be  spent  in  passing 
through  the  lock,  in  which  the  pressure  is  reduced.  At 
least  five  minutes  should  be  spent  for  each  atmosphere. 
Workmen  should  be  carefully  selected  and  gradually  accus- 
tomed to  the  work,  and  the  hours  of  labor  in  the  caisson 
should  at  first  be  short.  When  the  symptoms  occur,  it  is 
recommended  that  the  patient  should  at  once  be  put  back 
under  a  slight  atmospheric  pressure.  The  use  of  ergot  in 
large  doses  seems  to  be  of  service  during  the  acute  stages 
of  the  disease.     Morphine  may  be  required  for  the  neural- 

46 


722        MAXL'AL    OF   THE   PKACTICE    OF  MEDICINE. 

gic  pains.  The  paralytic  symptoms  are  to  be  treated  on 
the  same  principles  as  those  governing  the  treatment  of 
myelitis. 

{c)  DlSE.\SES  OF  THE    SuBSTANCE  OF  THE  CoRD. 

ACUTE  ANTERIOR  POLIOMYELITIS  (ATROPHIC 
SPINAL   PARALYSIS). 

Acute  anterior  poliomj-elitis  occurs  bdth  in  children  and 
in  adults.  An  infantile  and  an  adult  form  are  to  be 
described. 

Anterior  Poliomyelitis  in  Children. 

Etiology  and  Synonym. — The  disease  occurs  in  children 
between  two  and  five  \-ears  of  age,  and  is  equally  frequent 
in  boys  and  girls,  in  weakly  and  in  robust  subjects.  The 
majority  of  cases  appear  during  the  warm  summer  months. 
There  may  be  a  history  of  exposure  to  the  hot  sun,  of  a 
fall  or  an  injury,  or  the  condition  may  follow  some  acute 
infectious  disease,  especially  measles.  In  some  instances  it 
would  seem  that  the  disease  itself  was  of  an  infectious 
origin,  and  epidemics  of  the  disease  have  even  been  re- 
corded.    Synonym :  Infantile  paralysis. 

Pathology. — The  lesion  consists  in  the  degeneration  of 
the  anterior  motor  cells,  preferably  of  the  lumbar  and  cer- 
vical enlargements.  The  ganglionic  cells  become  swollen 
and  degenerated,  and  may  either  return  again  to  a  normal 
condition  or  may  become  atrophied. 

During  the  earlier  stages  the  gray  matter  about  the  motor 
cells  becomes  congested  and  infiltrated  by  leucocytes ;  later 
the  inflammation  becomes  chronic  and  results  in  an  in- 
creased production  of  connective  tissue.  As  the  anterior 
motor  cells  preside  over  the  nutrition  of  the  anterior  nerves 
and  the  muscles  to  which  they  are  distributed,  granular 
degeneration  and  atrophy  of  nerve  and  of  muscle  follow 
the  destructive  lesion  of  the  motor  cells.  The  lesion  is 
usually  bilateral,  and  affects  groups  of  cells  functionally 
associated  (Remak  describes  an  "  upper-arm  type,"  in  which 
the  supinator  longus  is  paralyzed,  with  the  biceps  and  the 


ACUTE  ANll'.RIOR    POLIOMYELITIS. 


723 


brachialis  anticus).  Through  the  anterior  motor  cells  pass 
fibres  from  the  central  regions  of  the  cord,  controlling  vas- 
cularity and  general  nutrition,  so  that  destructive  lesions  of 
the  anterior  cells  are  regularly  followed  by  imperfect 
growth,  cyanosis,  and  a  lowered  temperature  of  the  affected 
members. 

In  cases  of  long  standing  the  affected  cornua  become 
small  and  atrophied,  and  slight  sclerotic  changes  are  found 
in  the  pyramidal  tract. 


Fig.  63. — Diagrammatic  representation  of  the  symptoms  that  result  from  acute  destruc- 
tion of  the  anterior  cornua  of  the  spinal  cord  (Bramwell).  On  the  left  side  the  destruction 
of  the  nerve-cells  is  complete  :  the  anterior  nerve-roots,  motor  nerve-fibres,  and  the  muscles 
which  they  supply  are  all  degenerated ;  there  is  a  total  "  block  "  to  the  passage  of  voluntary 
motor  and  reflex  motor  impulses.  On  the  right  side  two-thirds  of  the  motor  cells  are  de- 
stroyed ;  two-thirds  of  the  muscular  area  connected  with  the  right  anterior  cornu  are  degen- 
erated and  atrophied  ;  one-third  (M)  remains  healthy,  and  can  be  made  to  contract  by 
voluntary  or  reflex  motor  impulses. 


The  symptoms  may  be  divided  into  three  stages : 
I.  TJie  Stage  of  Onset. — The  onset  begins  abruptly,  with 
fever  of  from  100°  to  103°  F.,  usually  accompanied  by  con- 
vulsions, twitching  of  the  muscles,  delirium,  or  even  coma. 
There  may  be,  in  older  children,  some  complaint  of  aching 
in  the  joints.  The  symptoms  may  be  well  marked,  or  there 
may  be  only  moderate  fever  which  may  pass  unnoticed. 
The  symptoms  of  this  stage  last  for  a  few  hours  or  for 
several  days. 


;24        .UAXCAL    OF   THE   PRACTICE    OF  MEDICIXE. 

2.  The  Stage  of  paralysis  is  distinctix'e  in  that  the  greatest 
degree  of  paral}'sis  is  reached  at  the  onset,  and  any  change 
afterward  is  for  the  better.  When  the  paralysis  has  remained 
stationary  for  twenty-four  hours  the  danger  of  further  ex- 
tension is  extremely  small.  The  distribution  of  the  paral- 
ysis depends  upon  the  situation  and  extent  of  the  lesion. 
The  type  is  paraplegic,  and  the  legs  are  more  frequently 
affected  than  the  arms,  in  the  proportion  of  4  :  i.  One  or 
both  legs  may  be  paralyzed,  or  the  muscles  of  the  upper 
extremities  may  be  affected  as  well,  or  may  be  paralyzed 
alone,  or  one  arm  and  one  leg  may  be  involved.  The 
paralyzed  muscles  are  those  functionally  associated.  The 
extensors  are  more  frequently  involved  than  the  flexors. 
All  the  muscles  of  a  limb  are  but  rarely  affected.  After  a 
stationary  period  of  from  two  to  six  weeks  some  of  the 
paralyzed  muscles  acquire  their  former  power,  while  others 
remain  paralyzed.  The  affected  muscles  are  flabby,  undergo 
wasting,  and  there  is  absence  of  all  reflex  action.  Fibrillary 
twitchings  may  occur  in  the  paralyzed  parts,  and  the  skin 
is  bluish  and  cold  to  the  touch.  The  affected  muscles 
show  the  reaction  of  degeneration,'  there  being  at  first  an 

^Reaction  of  D<;generation  (R.  D.). — Since  contractions  only  occur  on  clos- 
ing or  opening  the  galvanic  current,  and  as  there  are  but  two  poles,  the  anode 
or  positive  and  the  cathode  or  negative,  there  are  of  necessity  but  four  possible 
forms  of  contraction  : 

1.  When  the  cathode  is  on  the  muscle  and  the  anode  upon  a  neutral  and 
distant  point —  {a)  the  contraction  which  occurs  on  closing  the  current  (the 
cathodal  closure  contraction,  or  C.  C.  C.) ;  {b)  the  contraction  which  occurs 
on  opening  the  current  (cathodal  opening  contraction,  or  C.  O.  C). 

2.  When  the  anode  is  on  the  muscle  and  the  cathode  upon  a  distant  neutral 
point — {a)  the  contraction  which  occurs  on  closing  the  current  (anodal  closure 
contraction,  or  A.  C.  C);  (^)  the  contraction  which  occurs  on  opening  the 
current  (anodal  opening  contraction,  or  A.  O.  C). 

These  four  forms  of  contraction  occur  in  a  definite  order  of  intensity,  which 
order  dififers  in  health  and  in  disease.  In  health  the  order  is — C.  C.  C- 
A.  C.  C.-A.  O.  C.-C.  O.  C. 

The  A.  O.  C.  and  the  C.  O.  C.  are  usually  evident  only  with  currents  of 
such  intensity  as  to  cause  pain. 

In  degeneration  of  the  anterior  nerve  or  of  the  motor  cells  of  tlie  anterior 
comua  the  order  is  changed  to  the  "reaction  of  degeneration,"  in  the  follow- 
ing order  of  intensity :  A.  C.  C.-C.  C.  C.-C.  O.  C.-A.  O.  C.  The  character 
of  the  contraction  is  also  changed,  being  slow,  prolonged,  and  even  tetanic. 


ACUTE   ANTF.R/OR    I'OLIOMYEIJTIS.  725 

increase  and  then  a  decrease  in  the  galvanic  irritability,  and 
in  two  weeks  or  sooner  there  is  a  total  loss  of  farad ic  ex- 
citability. 

Negative  symptoms  are  important:  (i)  There  is  no 
secondary  involvement ;  (2)  the  bladder  and  the  rectum  are 
unimpaired;  (3)  trophic  changes  in  the  skin  do  not  occur; 
{4)  there  is  no  change  in  the  mental  condition  nor  in  the 
general  health;    (5)  the  cranial  nerves  are  not  involved. 

3.  Symptoms  of  pei'manait  deformity  are  due  (i)  to  the 
condition  of  the  paralyzed  limb — the  growth  is  retarded, 
the  limb  appears  atrophied,  withered,  cold,  and  bluish  ;  (2) 
to  increased  mobility  of  the  joints,  owing  to  the  relaxed  con- 
dition of  the  paralyzed  muscles  ;  (3)  to  muscular  contracture 
of  the  unparalyzed  muscles,  the  type  of  which  deformity  is 
club-foot. 

The  prognosis  for  life  is  good,  but  perfect  recovery  from 
paralysis  is  not  to  be  expected,  although  a  certain  amount 
of  improvement  almost  always  occurs.  The  following  rules 
may  be  given  in  the  way  of  estimating  the  extent  of  perma- 
nent paralysis:  Muscles  which  in  two  weeks  respond  to 
faradism  will  surely  recover,  while  muscles  not  thus  respond- 
ing will  remain  paralyzed  for  a  greater  or  less  time.  Mus- 
cles which  in  three  months  show  a  return  of  irritability  to 
faradism  will  recover  partially.  Muscles  which  do  not  re- 
spond to  faradism  in  six  months  will  never  recover. 

It  is  important  never  to  give  too  gloomy  a  prognosis  as 
long  as  the  faintest  contraction  is  produced  by  the  faradic 
current. 

Treatment. — During  the  stage  of  onset  the  spine  should 
be  cupped  and  fever  be  controlled  by  the  ordinary  measures. 
A  brisk  laxative  should  be  given  at  the  onset.  During  the 
earlier  part  of  the  stage  of  paral5'sis  ergot  and  sodium  bro- 
mide with  small  doses  of  potassium  iodide  should  be  given 
until  some  amount  of  improvement  appears.  During  this 
time  the  paralyzed  members  should  be  wrapped  in  cotton. 
In  two  or  three  weeks,  when  the  acute  stage  has  passed, 
strychnine  should  be  administered,  as  in  the  following 
prescription : 


•J 26       .U.LVr.lA    OF  THE   PRACTICE    OF  MEDICLXE. 

R.    Strychnin.x  sulphat.,  g*"- "gV  5 

Feni  pyropliosphat.,  gr.  j  ; 

Acid,  phosphoric,  dil,  TIX  iv  ; 

Sx'rup.  zingiberis,  ad  .^j. — M. 

Sig.    Such  a  dose  three  times  a  day  to  a  child  from  three 
to  five  )'ears  of  age. 

Tlie  affected  parts  should  be  carefuU)-  and  persistently 
rubbed  morning  and  evening,  and  the  muscles  should  at 
the  same  time  be  gently  kneaded.  The  faradic  current 
should  be  applied  daily  to  such  muscles  as  respond,  while 
to  the  paralyzed  muscles  the  slowly  interrupted  galvanic 
current  should  be  applied. 

For  the  permanent  deformities  much  good  can  be  done 
by  various  apparatus  or  by  surgical  measures. 

Anterior  Poliomyelitis  in  Adults. 

Males  are  more  usually  affected  than  females.  The  etiol- 
og}'-  and  pathology  are  the  same  as  in  children,  but  the  fol- 
lowing clinical  differences  are  observed:  (i)  The  onset  is 
less  acute  ;  (2)  the  cranial  nerves  may  be  involved  in  some 
cases  ;  (3)  rheumatoid  pains  may  be  present,  and  are  referred 
to  the  affected  muscles  and  joints  ;  (4)  muscular  tenderness 
may  be  extreme ;  (5)  fewer  muscles  are  affected  than  in 
children,  and  recovery  is  usually  more  complete  ;  (6)  owing 
to  the  development  of  the  limbs  of  an  adult,  the  withering 
and  retarded  growth  of  the  affected  member  are  not  so 
noticeable. 

Although  the  adult  cases  of  anterior  poliomyelitis  are 
described  as  the  counterpart  of  the  same  disease  in  children, 
there  is  strong  probability  that  the  disease  is  really  a  multi- 
ple neuritis.  Further  observations  are  necessary  to  deter- 
mine this  point. 

SUBACUTE  AND  CHRONIC  POLIOMYELITIS. 

Synonyra. — Duchenne's  paralysis. 

It  is  undecided  whether  this  disease  is  a  chronic  polio- 
myelitis or  a  multiple  neuritis.  The  pathology  is  therefore 
obscure. 


PROGKKSSIVIi    MUSCULAR   A'1'N()J'//Y.  727 

Etiology. — The  disease  is  rare,  and  is  almost  exclusively 
confined  to  adults. 

Symptoms. — The  onset  is  gradual,  and  is  characterized 
by  motor  weakness  which  increases  in  extent  and  ultimately 
leads  to  paralysis.  The  paralyzed  muscles  rapidly  atrophy, 
show  absence  of  reflexes,  and  the  R.  D.  can  be  obtained. 
There  is  no  sensory  involvement,  nor  is  the  bladder  or  the 
rectum  implicated.  The  symptoms  usually  begin  in  the 
legs  and  extend  to  the  trunk  and  the  upper  extremities 
(ascending  type)  ;  or  the  disease  may  be  first  noticed  in  the 
arms,  and  may  spread  to  the  legs  (descending  type).  The 
early  stages  of  the  descending  type,  in  which  the  arms  are 
first  affected,  may  closely  resemble  lead-paralysis. 

Prognosis. — In  the  majority  of  cases  a  certain  degree  of 
improvement  is  noticed  in  a  few  weeks  or  months,  but 
recovery  is  incomplete  except  in  rare  cases.  In  some 
instances  death  results  from  an  extension  of  the  disease  to 
the  medulla,  with  the  symptoms  of  bulbar  paralysis.  The 
duration  of  the  disease  is  usually  from  one  to  four  years. 

Treatment  is  that  of  the  acute  poliomyelitis  after  the 
febrile  stage  has  passed. 

PROGRESSIVE   MUSCULAR  ATROPHY. 

Etiology  and  Synonyms. — The  disease  is  most  frequent 
in  males  between  twenty-five  and  forty-five  years  of  age. 
An  hereditary  influence  is  often  observed,  and  there  are  cases 
in  which  the  disease  has  been  handed  dov/n  for  five  genera- 
tions. It  is  possible  that  some  of  these  hereditary  cases, 
however,  are  really  examples  of  idiopathic  muscular 
atrophy.  Excessive  physical  exertion,  mental  worry,  expos- 
ure to  wet  and  cold,  syphilis,  and  chronic  lead-poisoning 
have  been  ascribed  as  exciting  causes  ;  the  affection  has  been 
known  to  follow  measles,  typhoid  fever,  and  acute  rheuma- 
tism. Synonyvis :  Wasting  palsy;  Chronic  anterior  polio- 
myelitis. 

Pathology. — The  lesions  are  found  in  the  muscles,  nerves, 
and  cord.  The  muscles  are  wasted  and  pale,  and  the  fibres 
are  shrunken.  Certain  fibres  are  seen  to  have  entirely  disap- 
peared, leaving  empty  and  collapsed  sheaths.     The  wasting 


728        J/.I.Vr.lL    OF   THE   PKACTICE    OF  MEDICINE. 

of  the  muscle  is  not  en  masse,  but  fibre  after  fibre  is  picked 
out  in  the  process  of  atrophy.  There  may  be  an  increase 
in  the  interstitial  tissue.  The  atrophy  of  the  fibres  is  simple, 
and  granular  degeneration  is  not  apparent  as  in  infantile 
paralysis.  The  anterior  nerve-roots  emerging  from  the 
affected  part  of  the  cord  undergo  simple  atrophy,  and  fibre 
after  fibre  disappears.  In  the  cord  the  lesion  is  practically 
confined  to  the  anterior  cornua.    The  motor  ganglionic  cells 


Fig.  64. — Diagrammatic  representation  of  the  symptoms  that  result  from  slow  destruction 
of  the  multipolar  nerve-cells  of  the  anterior  cornu  (Bramwell).  On  the  left  side  the  disease 
is  in  an  early  stage.  One  nerve-cell  {a')  is  completely  destroyed.  Its  muscular  fibre  (1')  is 
completely  atrophied  Voluntary  motor  and  reflex  motor  impulses  are  "  blocked  "  at  the 
seat  of  the  lesion  {a').  One  nerve-cell  (//)  and  its  muscular  fibre  (a')  are  very  much  atro- 
phied, but  feeble  motor  and  reflex  impulses  can  still  pass  through  the  cell  to  the  muscle. 
Two  nerve-cells  (cV)  are  healthy.  Their  muscular  fibres  are  of  normal  bulk,  and  can  be 
made  to  contract  either  by  voluntary  or  reflex  impulses.  On  the  right  side  the  disease  is 
much  more  advanced.  The  muscular  area  is  three-fourths  degenerated.  There  is  a  total 
"  block  "  at  a  and  a.  This  condition  represents  a  late  stage  of  progressive  muscular  atro- 
phy.    The  atrophy  of  the  muscular  fibres  is  represented  as  simple. 

waste,  lose  their  processes,  and  one  after  another  undergoes 
simple  atrophy  (Fig.  64).  Sclerotic  changes  are  usually 
found  in  the  direct  and  crossed  pyramidal  tract,  and  when 
these  changes  are  sufficiently  marked  to  give  rise  to  symp- 
toms, the  name  of  "  amyotrophic  lateral  sclerosis  "  is  given 
to  the  resulting  complex  lesion  This  form  of  disease  will 
be  separately  considered.  In  many  cases  the  disease  extends 
upward  to  involve  the  motor  nuclear  cells  in  the  medulla. 
The  symptoms  begin  gradually  and  insidiously.     It  is 


PROGRKSSfVP:   MUSCULAR  ATROR/fY.  729 

noticed  that  the  muscles  tire  easily,  are  not  so  firm  as  nor- 
mal, and  ache  after  slight  exertions.  Fibrillary  contractions 
may  be  observed.  The  atrophy  is  usually  first  noticed  in 
the  interossei  muscles  and  in  those  of  the  ball  of  the  thumb. 
Motor  weakness  is  proportionate  to  the  extent  of  the 
atrophy,  as  there  is  in  this  disease  no  essential  paralysis. 
Advanced  atrophy  of  the  interossei  give  the  hand  the 
"  griffin-claw  "  appearance,  in  which  flexion  of  the  last  two 
phalanges  is  associated  with  extension  of  the  first  phalanx 
at  the  metacarpal  joint.  Occasionally  the  deltoid  is  the  first 
muscle  to  suffer,  and  its  atrophy  may  present  a  deformity 
of  contour  closely  resembling  a  subglenoid  dislocation  of 
the  humerus. 

In  90  per  cent,  of  the  cases  the  disease  begins  in  the  hand 
or  shoulder.  More  exceptionally  the  affection  may  first 
show  itself  in  the  lumbar  or  abdominal  muscles,  and  still 
more  rarely  in  the  muscles  of  the  legs.  The  atrophied 
muscles  are  flaccid,  and  usually  retain  their  normal  elec- 
tric reactions,  for  what  muscle  is  left  is  good.  In  late 
cases,  however,  with  rapid  atrophy  the  R.  D.  may  finally 
appear.  Reflexes  are  diminished  according  to  the  amount 
of  the  atrophy.  Fibrillary  twitchings  are  not  infrequently 
present.  Atrophy  proceeds  from  muscle  to  muscle  in 
the  order  of  the  juxtaposition  of  their  nerve-nuclei  in 
the  cord.  Bilateral  symmetry  is  usually  preserved,  al- 
though the  wasting  may  be  more  marked  on  one  side 
than  the  other.  Owing  to  the  contracture  of  unparalyzed 
muscles  various  deformities  result;  the  "  grififin-claw,"  or 
"  main  de  griffe,"  has  already  been  described.  When  the 
lumbar  muscles  are  implicated  the  back  is  arched  and  the 
line  of  gravity  falls  behind  the  sacrum.  When  the  abdom- 
inal muscles  are  affected  the  back  is  also  arched,  but  the 
line  of  gravity  falls  in  front  of  the  sacrum. 

In  course  of  time  all  the  voluntary  muscles  may  become 
implicated,  so  that  the  patient  is  practically  reduced  to 
"  skin  and  bone."  The  normal  appearance  of  the  facial 
muscles  is  in  strong  contrast  to  the  wasting  of  the  rest  of 
the  body.  Ophthalmoplegia  externa  and  bulbar  paralysis 
may  develop  toward  the  close  of  the  disease. 


730        MAXCAL    OF  THE   rRACTJCE    OF  MEDICIXE. 

The  diagnosis  of  "  main  de  grifife  "  from  lesion  of  the  uhiar 
nerve  is  made  by  the  absence  of  sensor\'  symptoms.  Tlie 
diagnosis  from  idiopathic  muscular  atroph\-  is  to  be  made 
by  tlie  different  order  of  distribution  of  the  atropliies  in  the 
latter  disease,  and  by  the  fact  that  the  latter  condition  usually 
occurs  in  \-oung  children.  Amyotrophic  lateral  sclerosis  is 
to  be  excluded  by  the  absence  of  spasm  and  rigidity. 

Prognosis. — The  course  of  the  disease  is  usually  progres- 
sive. Death  may  result  from  exhaustion,  from  bulbar  paral- 
ysis, or  from  respiratory  affections.  The  disease  may  be- 
come quiescent  at  any  time,  and  the  patient  may  live  for 
years.  These  cases  are  often  seen  as  freaks  in  museums, 
under  the  name  of  "  living  skeletons." 

Treatment  is  of  no  avail.  The  general  nutrition  of  the 
muscles  should  be  maintained  by  massage  and  electricity, 
and  strjxhnine,  arsenic,  and  nitrate  of  silver  may  be  given 
internally.  If  the  muscles  of  respiration  be  affected,  extra- 
ordinary care  should  be  taken  to  avoid  cold,  as  even  a 
trifling  bronchitis  may  terminate  fatally. 

AMYOTROPHIC    LATERAL    SCLEROSIS. 

Etiology. — This  condition  is  really  one  of  progressive 
muscular  atrophy  in  which  sclerosis  in  the  lateral  columns 
is  sufficiently  marked  to  produce  symptoms,  and  is  not  at 
present  regarded  as  an  independent  disease.  The  etiology 
is  therefore  the  same  as  that  of  progressive  muscular  atrophy, 
except  that  the  disease  may  occur  after  the  age  of  seventy 
as  a  senile  change. 

Pathology. — The  lesions  are  the  same  as  those  of  pro- 
gressive muscular  atrophy,  except  that  the  direct  and  crossed 
p\Tamidal  tracts  show  degeneration  and  sclerotic  change, 
and  the  motor  nuclear  cells  of  the  pons  and  of  the  medulla 
are  more  frequently  involved. 

The  symptoms  result  from  the  combination  of  progres- 
sive muscular  atrophy  and  lateral  sclerosis.  Wasting  and 
weakness  progress,  with  rigidity,  contractures,  and  exagger- 
ated reflexes.  In  the  hands  and  arms  the  atrophy  and  weak- 
ness are  especially  well  marked,  while  in  the  legs  typical 
spastic  paraplegia  develops  early.     Fibrillary  twitchings  of 


BULBAR   PARALYSIS.  73  I 

the  muscles  are  commonly  observed.  There  are  no  sensory 
disturbances,  and  the  bladder  and  the  rectum  are  under  full 
control.  Ultimately  the  rigidity  and  muscular  wasting  be- 
come general,  paralysis  results,  and  symptoms  of  bulbar 
paralysis  or  of  ophthalmoplegia  externa  make  their  appear- 
ance. 

The  prognosis  is  not  as  good  as  in  progressive  muscular 
atrophy,  as  the  disease  is  seldom  if  ever  arrested.  Death 
results  in  from  one  to  four  years. 

Treatment  is  of  no  avail.  Long-continued  rest  in  bed 
has  been  recommended. 

BULBAR  PARALYSIS. 

Synonym. — Glosso-labio-laryngeal  paralysis. 
Two  forms  of  bulbar  paralysis  are  recognized — the  acute 
and  the  chronic. 

1.  Acute  bulbar  paralysis  results  (i)  from  small  hemor- 
rhages into  the  medulla ;  (2)  from  areas  of  softening  follow- 
ing embolism  or  thrombosis ;  (3)  from  an  acute  inflamma- 
tory affection  analogous  to  anterior  poliomyelitis ;  (4)  as  a 
terminal  lesion  of  Landry's  paralysis.  The  lesion  is  almost 
regularly  bilateral. 

The  symptoms  are  those  of  the  chronic  form,  differing 
only  in  their  acuteness  of  onset.  There  may  be  hemiplegia 
or  crossed  facial  paralysis.  These  acute  cases  prove  rapidly 
fatal,  although  in  rare  instances  the  condition  may  become 
chronic. 

2.  Chronic  bulbar  paralysis  is  commonly  associated  with 
similar  degeneration  of  the   motor  cells  of  the  spinal  cord. 

The  condition  is  rare  before  the  age  of  forty,  and  usually 
appears  as  the  terminal  event  of  progressive  muscular 
atrophy,  of  amyotrophic  lateral  sclerosis,  or  of  Duchenne's 
paralysis. 

Symptoms. — There  is  a  progressive  palsy  of  the  tongue, 
lips,  palate,  pharynx,  and  laryngeal  muscles,  resembling  in 
character  the  muscular  changes  of  progressive  muscular 
atrophy.  The  tongue  becomes  tremulous  and  is  protruded 
with  difficulty,  and  finally  the  lingual  and  dental  consonants 
d,  /,  n,  r,  and  t  cannot  be  pronounced.     The  tongue  atro- 


732        J/AXr.lL    OF   THE   PRACTICE    OF  MEDICLXE. 

phies.  Chewing  and  swallowing  are  impaired.  The  lips  be- 
come paralyzed  and  tremulous,  the  patient  cannot  whistle, 
and  the  lip-letters  b,  f,  f,  o,  and  //  cannot  be  pronounced. 
Saliva  drools  from  the  mouth.  There  may  be  an  emotion- 
less expression,  from  facial  paresis  and  atrophy.  The 
pharynx  becoming  paralyzed,  food  regurgitates  or  cannot 
be  swallowed.  The  lar)'ngeal  muscles  waste,  so  that  the 
voice  is  weak,  almost  inaudible,  but  extreme  degrees  of 
abductor  paralysis  are  rare.  Cough  becomes  impossible, 
and,  the  larynx  being  unprotected,  aspiration-  or  deglutition- 
pneumonia  is  rendered  possible.  There  are  no  sensory 
symptoms,  and  the  mind  is  clear  though  emotional.  Taste 
is  not  impaired.  Pulmonary  and  cardiac  crises  occur  when 
the  nucleus  of  the  vagus  is  affected.  Severe  dyspnoea 
appears  on  exertion,  and,  later,  furious  spontaneous  attacks 
of  suffocation,  with  cyanosis  and  a  sense  of  extreme  fulness 
in  the  chest,  may  appear. 

The  cardiac  crises  consist  of  a  rapid  and  excessively 
feeble  heart-action,  pallor,  anxiety,  and  a  sense  of  impend- 
ing death. 

The  diagnosis  is  not  usually  one  of  difficulty.  The 
condition,  however,  may  be  simulated  by  a  bilateral  lesion 
in  the  lower  portion  of  the  third  frontal  convolution 
("  pseudo-bulbar  paralysis  of  cerebral  origin"). 

Prognosis. — The  duration  of  the  disease  is  from  one  to 
four  years,  with  periods  of  temporary  inactivity.  Death 
results  from  inanition,  from  aspiration-pneumonia,  or  from 
heart-failure  during  a  cardiac  crisis. 

Treatment. — The  only  thing  that  can  be  done  is  to 
advise  the  feeding  of  the  patient  by  the  stomach-tube  when 
deglutition  becomes  impaired. 

OPHTHALMOPLEGIA. 

This  rare  disease  is  due  to  the  progressive  atrophy  of  the 
nuclei  of  the  cranial  nerves  of  the  eye  or  the  eyeball.  Ac- 
cording to  whether  the  external  or  the  internal  muscles  are 
affected,  there  are  described  ophthalmoplegia  externa  and 
ophthalmoplegia  interna. 

OpJithalnioplcgia   cxtcr)ia  may  be    found   associated  with 


LATERAL    SCLE/WS/S.  733 

generaf  paresis,  progressive  muscular  atrophy,  and  loco- 
motor ataxia,  or  the  nuclear  degeneration  may  be  due  to 
the  pressure  of  tumors  or  to  basilar  meningitis.  Mental 
disorders  are  present  in  about  one-fifth  of  the  cases,  and 
atrophy  of  the  optic  nerve  may  coexist.  There  is  a  gradual 
loss  of  power  in  the  extrinsic  muscles  of  the  eyeball,  start- 
ing first  in  the  levator  muscles  of  the  lid  and  in  the  superior 
recti.  The  loss  of  power  finally  becomes  absolute.  Ptosis, 
squint,  and  double  vision  appear  during  the  earlier  stages, 
but  later  the  eyeball  becomes  fixed  and  immobile  and  may 
protrude.     The  disease  is  essentially  chronic. 

Ophthalmoplegia  interna  causes  loss  of  pupillary  reflex 
and  of  power  of  accommodation,  and  is  usually  associated 
with  locomotor  ataxia  or  with  general  paresis.  The  con- 
dition may  be  combined  with  the  external  form.  Ophthal- 
moplegia interna  may  result  from  nuclear  degeneration  or 
from  disease  of  the  ciliary  ganglion. 

LATERAL  SCLEROSIS  (SPASTIC  PARAPLEGIA). 

Lateral  sclerosis  may  be  primary  or  secondary. 

Primary  lateral  sclerosis  is  so  rare  a  condition  that  by 
some  its  existence  is  doubted.  It  is  said  to  be  induced  by 
syphilis,  over-work,  exposure,  and  sexual  excesses,  and  to 
attack   males   of  middle   life. 

Secondary  lateral  sclerosis  is  the  most  frequent  form  of 
spastic  paraplegia,  and  results  from  any  lesion  destroying 
the  motor  cells  in  the  cerebral  cortex  or  cutting  off  the 
pyramidal  fibres  from  their  trophic  centres  in  the  motor 
cortical  cells.  These  lesions  may  be  cerebral  or  spinal. 
Such  lesions  are — (i)  Tumors,  softening,  or  hemorrhage  in 
the  brain,  destroying  the  motor  tract  in  one  hemisphere. 
Secondary  sclerosis  is  found  below  the  lesion  in  the  anterior 
median  column  and  in  the  opposite  lateral  pyramidal  tract. 
(2)  Congenital  malformation,  hydrocephalus,  or  bilateral 
meningeal  hemorrhage  affecting  both  motor  tracts.  In 
these  cases  the  descending  degeneration  is  bilateral,  involv- 
ing both  anterior  median  columns  and  crossed  pyramidal 
tracts.  (3)  Any  lesion  in  the  cord,  unilateral  or  bilateral, 
that  separates  the  fibres  of  the  motor  tract  from  their  trophic 


734        MAXr.lL    OF   THE   rKACTICE    OF  MEDICIXE. 

centre  in  the  motor  cortex  of  the  brain.  Such  lesions  are 
transverse  myehtis,  hemorrhage  into  the  cord,  or  slow  com- 
pression of  the  core!  by  tumor,  disease,  fracture,  or  dislocation 
of  the  vertebra,  and  menini^eal  hemorrhage.  (4)  The  lateral 
columns  may  be  involved  with  other  tracts  in  the  cord — 
with  the  cells  of  the  anterior  horns  causing  amyotrophic 
lateral  sclerosis,  with  the  posterior  columns  causing  ataxic 
paraplegia.  These  combined  lesions  will  be  individually 
described. 

Patholog-y. — The  lesion  is  found  to  be  limited  to  the 
lateral  motor  tracts.  The  anterior  median  columns  may  be 
involved  in  the  case  of  a  primary  lesion  in  the  brain.  There 
is  an  increase  in  the  connective-tissue  framework,  and  a 
destruction  and  disappearance  of  the  axis-cylinders  of  the 
nerve-fibres. 

Symptoms. — Of  the  Primary  Form. — There  are  first 
noticed  a  loss  of  endurance  in  walking,  and  stiffness  and 
rigidity  of  the  muscles.  The  muscular  weakness  is  pro- 
gressive, and  merges  into  paralysis  of  voluntary  motion. 
Coincident  with  the  weakness  there  is  a  rigidity  of  the 
affected  limbs  from  a  more  or  less  continual  spasm  of  the 
muscles.  From  time  to  time  clonic  spasms  occur,  especially 
during  the  night,  during  which  the  legs  are  twitched  or 
suddenly  jerked  out.  The  gait  becomes  "  spastic  " — the 
toes  stick  to  the  ground,  the  knees  touch  or  overlap  in 
■walking,  and  the  leg  is  in  a  condition  of  spasmodic  tension, 
or  even  shows  distinct  clonus  when  the  ball  of  the  foot  rests 
upon  the  ground.  The  trunk  is  usually  thrown  forward  by 
tonic  contractures  of  the  calf-muscles,  so  that  crutches  or 
canes  held  far  in  advance  of  the  body  become  necessary. 
The  power  of  locomotion  is  finally  lost.  The  affected 
muscles  do  not  atrophy,  and  the  R.  D.  is  not  present.  The 
reflexes  are  regularly  ijicreased.  The  knee-jerk  is  exces- 
sive and  prolonged,  and  may  be  radiated  to  the  arms  or  to 
the  opposite  leg.  Ankle-clonus  is  easily  obtained.  There 
are  no  essential  sensory  symptoms,  though  there  may  be 
dull  pains  in  the  muscles,  and  the  bladder  and  rectum  are 
not    usually   involved    until   late  in    the    disease.      Ocular 


LOCOMOTOR  ATAXIA.  735 

symptoms  are   rare.     The  arms  may  escape  altogether,  or 
rigidity  may  appear  as  a  late  manifestation  of  the  disease. 

Of  the  Secondary  Form. — The  symptoms  are  bilateral  or 
unilateral  according  as  to  whether  one  motor  tract  or  both 
are  affected.  Cerebral  lesions  usually  lead  to  unilateral 
sclerosis.  The  symptoms  appear  rapidly  or  gradually  ac- 
cording to  the  nature  of  the  primary  lesion.  "  Late  rigid- 
ity "  with  hemiplegia  following  cerebral  hemorrhage  is 
synonymous  with  secondary  lateral  sclerosis. 

Spastic  paraplegia  of  infants  is  usually  a  birth-palsy  due 
to  meningeal  hemorrhage.  In  other  cases  the  condition 
arises  from  an  arrested  development  of  the  pyramidal  tracts. 
The  symptoms  may  be  bilateral,  and  the  arms  are  not  infre- 
quently involved.  Idiocy,  imbecility,  and  other  mental  de- 
fects are  usually  present. 

The  diagnosis  from  hysterical  spastic  paraplegia  may  be 
one  of  great  difficulty,  as  the  hysterical  form  may  exactly 
reduplicate  the  symptoms  of  the  organic  disease.  In  favor 
of  the  hysterical  condition  are  (i)  the  sudden  development 
of  symptoms,  (2)  the  history  of  hysterical  attacks  in  the  past, 
(3)  the  presence  of  anaesthesia,  hyperaesthesia,  or  other 
hysterical  manifestations,  and  (4)  the  sudden  remission  of 
muscular  contractions,  which  in  the  organic  form  should  be 
more  permanent. 

Prognosis. — The  course  of  the  disease  is  chronic,  extend- 
ing over  many  years.'  The  disease  is  the  least  fatal  of  all 
the  chronic  spinal  affections.  Its  progress  may  be  arrested 
at  any  time. 

Treatment. — In  syphilitic  cases  mercury  and  iodide  of 
potassium  may  be  tried  ;  strychnine  is  contraindicated ;  the 
bromides  may  be  of  use  in  reducing  the  condition  of  over- 
reflexes ;  otherwise^ there  is  no  medicinal  treatment  of  any 
value. 

LOCOMOTOR   ATAXIA. 

Etiology  and  Synonyms. — This  disease  occurs  in  males 
ten  times  as  frequently  as  in  females,  and  is  most  common 
between  thirty  and  fifty  years  of  age.  Its  occurrence  under 
the  age  of  twenty-five  is  rare.  The  great  predisposing  cause 
is  syphilis,  which  precedes  the  disease  in  two-thirds  of  the 


73<3        M.LVL'AL    OF   THE   PRACTICE    OF  MEDICE\E. 

cases.  Amoiii::^  exciting  causes  are  sexual  excesses,  great 
pln^sical  exertion,  and  repeated  exposures  to  wet  and  cold. 
Synonyms :  Posterior  spinal  sclerosis ;  Tabes  dorsalis. 

Patholog-y. — There  is  a  sclerosis,  beginning  first  in  the 
middle  zone  of  the  column  of  Burdach  and  in  the  column 
of  Lissauer  (the  narrow  marginal  zone  lying  between  the 
posterior  horn  and  the  pyramidal  tract),  and  extending  to 
the  column  of  Goll  and  the  remainder  of  the  column  of 
Burdach  (Fig.  65).  The  network  of  fibres  about  the  vesic- 
ular columns  of  Clarke  are  affected  by  the  sclerotic  pro- 
cesses early  in  the  disease.  The  lesion  begins  in  the  lumbo- 
sacral region  and  extends  upward  throughout  the  cord.  In 
long-standing   cases   the   sclerosis    extends    to   the  lateral 


Fig.  65. — Localization  of  the  lesion  in  successive  stages  of  locomotor  ataxia. 

columns  and  leads  to  the  degeneration  of  the  pyramidal 
and  direct  cerebellar  tracts.  The  posterior  nerve-roots 
show  the  lesions  of  a  degenerative  neuritis,  and  become 
small  and  atrophic.  These  nerve-changes  are  frequently 
first  observed  in  the  cutaneous  filaments,  and  may  even  pre- 
cede the  sclerosis  of  the  posterior  columns.  The  meninges 
over  the  lateral  and  posterior  columns  are  thickened  and 
abnormally  adherent ;  their  blood-vessels  show  the  changes 
of  arterio-sclerosis.  Besides  neuritis  there  may  be  muscu- 
lar atrophy.  Atrophy  may  occur  in  any  of  the  cranial 
nerves,  especially  the  optic,  third,  auditory,  and  pneumo- 
gastric  nerves.  There  may  be  sclerosis  of  the  restiform 
bodies  or  of  the  inferior  peduncles  of  the  cerebellum,  or 
sclerotic  areas  in  the  hemispheres  may  resemble  the  lesions 
of  general  paresis. 

The  disease  is  not  yet  thoroughly  understood,  and  three 
theories  are  advanced  to  account  for  the  lesions:  (i)  That 
there  is  a  primary  sclerosis  of  the  posterior  columns;  (2)  that 
the  sclerosis  is  dependent  upon  arterial  degeneration  of  the 


LOCOMOTOR  ATAXIA.  73/ 

vessels  entering  the  posterior  root-zones ;  and  (3)  that  the 
disease  originates  in  the  gangha  of  the  posterior  nerve-roots, 
with  secondary  degeneration  of  the  sensory  fibres  entering 
the  cord  from  these  ganglia,  with  secondary  sclerotic  changes 
in  their  course. 

The  symptoms  of  locomotor  ataxia  may  be  divided  into 
three  stages:  (ij  The  stage  of  pain;  (2)  that  of  ataxia,  and 
(3)  that  of  paralysis. 

I.  Stage  of  Pain. — The  following  are  the  characteristic 
symptoms  of  this  pre-ataxic  stage  :  . 

ia)  Pain,  of  a  paroxysmal  darting  character,  appears  in  90 
per  cent,  of  the  cases.  The  pains  are  bilateral,  dart  down 
the  legs,  and  are  generally  referred  to  the  deeper  structures 
of  the  limb.  Their  distribution  is  irregular,  rarely  corre- 
sponding to  the  nerve-trunks.  The  characteristics  of  the 
pains  are  their  "  lightning "  character  and  the  absence  of 
local  tenderness.  Occasionally  trophic  eruptions  appear.  In 
rarer  instances  the  pain  may  be  diffused  and  superficial,  or 
the  feeling  may  be  described  as  one  of  intense  heat  or  cold. 
Lightning  pains  in  the  arms  occur  when  the  lesion  extends 
to  the  cervical  enlargement  of  the  cord.  Pain  may  be 
absent  or  insignificant  in  a  few  cases  beginning  with  rapid 
optic  atrophy,  and  in  these  patients  ataxia  is  not  apt  to  be 
developed. 

{b)  There  are  symptoms  of  perverted  sensation.  The 
patient  may  complain  of  numbness  or  tingling  in  the  legs  or 
the  feet,  or  may  feel  as  though  he  were  walking  on  cotton 
or  on  air-bags  instead  of  on  solid  ground.  There  may  be  a 
sensation  of  tightness  and  pressure  about  the  waist.  In  some 
instances  the  "  muscular  sense  "  becomes  so  impaired  that 
the  patient  cannot  tell  in  what  position  the  limbs  are  placed 
when  the  eyes  are  shut.  During  this  first  stage,  however, 
the  sensory  symptoms  are  subjective,  and  areas  of  anaesthe- 
sia or  of  retarded  sensation  cannot  be  demonstrated. 

{c)  Loss  of  kncc-jcrk  (Westphal's  symptom)  is  one  of  the 
earliest  indications  of  the  disease,  and  its  association  with 
the  lightning  pains  and  the  ocular  symptoms  forms  a  symp- 
tom-group absolutely  diagnostic  of  locomotor  ataxia.  The 
superficial  reflexes  remain  good. 
47 


y^S       MAXi'Al.    OF    THE   PRACTICE    OF  MEDICINE. 

id)  Ocular  Symptoms. — There  may  be  ptosis,  strabismus, 
double  vision,  or  in  rare  cases  ophthalmoplegia  externa. 
Contracted  pupils  ("  myosis  spinalis  ")  are  frequent,  but  not 
constant.  Optic  atrophy  may  develop,  causing  dimness  and 
restricted  field  of  \ision  and  color-blindness,  and  the  atrophy 
may  progress  until  the  vision  is  entirely  lost.  Cases  in 
which  the  atropln-  of  the  optic  nerve  appears  early  and  pro- 
gresses rapidly  do  not  seem  to  develop  the  second  stage  of 
ataxia.  The  Argyll-Robertson  pupil  occurs  during  the  first 
stage  in  over  80  per  cent,  of  the  cases.  In  this  condition 
the  pupils  do  not  react  to  light,  but  accommodation  to  dis- 
tance is  preserved. 

{c)  Bladder  and  Rectum. — There  may  be  lightning  pains 
referred  to  these  viscera.  Constipation  is  usually  obstinate. 
Micturition  may  be  frequent  and  painful,  or  there  may  be 
imperfect  control  of  the  bladder,  with  dribbling,  partial  re- 
tention of  urine,  and  cystitis.  Impotence  may  appear,  oc- 
casionally preceded  by  priapism  and  sexual  excitement. 

2.  Stage  of  Ataxia. — Old  symptoms  persist  while  new 
symptoms  appear.  The  lightning  pains  may  continue,  but 
they  tend  to  become  less  and  less  severe.  Objective  sensory 
disturbances  can  now  be  demonstrated  ;  there  may  be  areas 
of  anaesthesia  or  hyperaesthesia  or  of  retarded  sensation. 
The  power  of  localizing  pain  may  be  lost,  and  the  muscular 
sense  becomes  more  and  more  impaired,  so  that  motions 
cannot  be  made  accurately  without  the  aid  of  sight ;  hence 
a  blind  ataxic  patient  may  become  almost  totally  helpless. 
The  eye-symptoms  noted  above  continue,  or  they  may 
appear  for  the  first  time.  Optic  atrophy  occurs  in  20  per 
cent,  of  the  cases,  and  its  antagonism  to  the  development  of 
ataxia  has  already  been  noted.  There  is  usually  difficulty 
in  emptying  the  bladder,  and  retention  with  cystitis  is  apt  to 
result.  Deafness  may  occur  from  neuritis  of  the  auditory 
nerve.  The  characteristic  symptoms  of  the  second  stage  are 
ataxia,  visceral  crises,  and  trophic  changes. 

Ataxia  usually  develops  in  the  legs,  although  in  rare 
instances  the  arms  may  be  first  involved.  The  patient  loses 
the  power  to  co-ordinate  muscular  movements  so  as  to  pro- 
duce  a  harmonious   result      There  is  an  inability  to  stand 


LOCOMOTOR  ATAXIA. 


739 


Steadily  with  the  eyes  shut  (Romberg's  symptom),  to  walk 
readily  in  the  dark,  or  to  turn  quickly  without  fallinf;.  In- 
co-ordination  of  the  arms  is  usually  apparent  in  writing,  in 
buttoning  the  clothes,  or  in  handling  the  knife  and  fork 
when  at  table.  Ataxia  is  demonstrated  by  having  the 
patient  stand  or  walk  with  the  eyes  shut,  or  touch  toe  to 


Fig.  66.— Locomotor  ataxia,  showing  Charcot's  knee  (personal  observation). 

heel  or  heel  to  knee,  or  to  rapidly  touch  the  nose  with  the 
finger  when  the  eyes  are  shut.  The  gait  becomes  character- 
istic. The  legs  are  far  apart ;  the  body  is  inclined  forward, 
so  that  the  support  of  a  cane  may  be  a  necessity.  The  foot 
is  lifted  high  at  each  step,  and  is  planted  forcibly  upon  the 
ground  with   a  stamp   or  a   slap.     The  muscular  power  is 


740      .y.txr.iL  of  the  practicf.  of  mkpiclxe. 

maintained,  and  the  nutrition  of  the  muscles,  except  toward 
the  close,  is  usually  unimpaired. 

Visceral  crises  are  characterized  b\-  paroxs\-mal  pain  in 
the  various  viscera.  Thus,  gastric,  laryngeal,  renal,  cardiac, 
rectal,  and  genital  crises  are  described,  of  which  the  gastric 
and  the  laryngeal  are  the  most  common,  and  are  due  to 
neuritis  of  the  pneumogastric  nerve.  A  gastric  crisis  consists 
of  severe  paroxysmal  pain,  vomiting,  and  hyperacidity.  There 
may  be  hn^matemesis.  The  laryngeal  crisis  gives  rise  to 
dyspnoea,  hoarse  coughing,  and  intense  pains  in  the  shoulder 
and  spine.  There  may  be  fatal  asphyxia,  or  the  larynx  may 
become  anaesthetic,  so  that  death  may  result  from  aspiration- 
pneumonia.  Renal  crises  may  reproduce  the  symptoms  of 
calculus.  Cardiac  crises  give  rise  to  pain  in  the  heart,  ir- 
regular and  feeble  pulse,  and  syncope. 

Trophic  CJiangcs. — Of  these  changes,  the  most  common 
are  the  arthropathies  or  joint-lesions  known  as  "Charcot's 
joints"  (Fig.  66),  which  occur  in  from  5  to  10  per  cent,  of 
all  cases.  These  changes  are  most  common  in  the  larger 
joints,  especially  the  knee.  The  joint  swells  rapidly  from 
serous  effusion,  the  articular  ends  of  the  bones  become 
absorbed,  ligaments  soften  so  that  dislocations  and  unnatural 
mobility  become  evident,  and  there  is  an  irregular  produc- 
tion of  new  bone  about  the  edges  of  the  articular  surfaces. 
These  changes  are  essentially  trophic  in  character,  but  an 
exciting  cause  may  be  found  in  some  traumatism  of  which 
the  patient  is  unconscious  owing  to  the  anaesthesia  of  the 
parts.  The  joint-lesions  progress  without  fever  and  without 
pain,  and  the  symptoms  may  develop  in  from  twenty-four  to 
forty-eight  hours. 

The  chief  points  of  differential  diagnosis  from  rheuma- 
toid arthritis  are  as  follows  : 

Rheumatoid  Arthritis.  Charcot's  Joint. 

Hypertrophy.  Atrophy. 

Painful.  Painless. 

Limited  mobility.  Increased  mobility. 

Slow  process.  Rapid  process. 

Small  joints.  Large  joints. 

Symmetry  of  lesions.  No  symmetry ;  usually  unilateral. 

No  ataxia.  Ataxia. 


LOCOMOTOR  ATAXIA.  74 1 

Besides  Charcot's  joint  other  trophic  changes  may  occur. 
The  bones  may  rarefy  and  be  the  seat  of  spontaneous  frac- 
ture. Absorption  of  the  articular  ends  of  the  bones  leads  to 
dislocation.  There  may  be  herpes,  cedcma,  local  sweating, 
perforating  ulcer  of  the  foot,  inflammation  and  falling  of  the 
nails,  and  atrophy  of  muscles. 

■ij.  The  stage  of  paralysis  occurs  when  the  patient  loses 
the  power  of  walking.  Paraplegia  develops  from  involve- 
ment of  the  lateral  columns.  The  patient  may  develop 
during  the  second  or  third  stage  of  the  disease  general 
paresis,  melancholia,  or  delusional  insanity.  Cystitis  and 
pyelo-nephritis  are  apt  to  develop.  Pneumonia  or  bed- 
sores may  hasten  the  final  issue. 

Prognosis. — The  course  of  the  disease  is  chronic,  lasting 
from  twenty  to  forty  years.  Ataxia  is  rarely  developed 
until  from  five  to  eight  years  after  the  beginning  of  the  dis- 
ease. There  have  been  described  rare  instances  of  acute 
ataxia  in  which  the  patient  became  bedridden  within  a  few 
months.  Recovery  never  occurs,  although  the  disease  may 
be  arrested  at  any  time,  especially  during  the  first  stage, 
and  may  even  show  periods  of  temporary  improvement. 
The  disease  itself  seldom  causes  death. 

Treatment. — A  quiet  and  regular  mode  of  life  should  be 
enjoined.  Alcoholic  and  sexual  excesses  should  be  abso- 
lutely interdicted.  Rest  in  bed  for  several  months  is  some- 
times serviceable  in  modifying  the  neuralgic  pains.  Spinal 
douches,  tepid  or  cool,  may  be  ordered  daily,  but  extreme 
temperatures  should  be  avoided. 

The  medicinal  treatment  is  somewhat  varied,  as  there 
seems  to  be  no  drug  capable  of  exerting  a  beneficial  effect 
upon  the  disease  to  any  appreciable  extent.  The  drugs  that 
have  been  recommended  are  mercury  and  iodide  of  potas- 
sium, especially  in  recent  syphilitic  cases;  arsenic  in  full 
doses ;  nitrate  of  silver  in  gr.  \  doses  three  times  daily  for 
periods  of  not  longer  than  two  months ;  chloride  of  sodium 
and  gold  ;  chloride  of  aluminum  in  2-  to  4-grain  doses;  and 
ergot  in  moderate  doses. 

The  pains  may  be  relieved  by  counter-irritation  to  the 
spine,  preferably  by  the  thermo-cautery  applied  every  two 


742        MAXCAL    OF   THE   PRACTICE    OF  MEDICIXE. 

or  four  weeks,  but  the  application  of  counter-irritants  should 
not  be  severe,  especially  o\'er  anaesthetic  portions  of  the 
skin,  as  destructive  trophic  changes  may  ensue.  Pain  may 
also  be-  relieved  by  phenacetinc  or  antipyrine,  but  opium 
should  be  given  with  caution,  for  fear  of  the  habit  being 
formed. 

The  treatment  by  suspension  is  now  being  abandoned,  as 
the  published  results  do  not  agree  with  the  first  enthusiastic 
reports.  Charcot's  joints  are  to  be  treated  by  rest  and 
apparatus.  Morphine  may  be  indicated  during  the  visceral 
crises. 

HEREDITARY   ATAXIA. 

Etiology  and  Synonym, — The  disease  may  or  may  not 
be  hereditary ;  in  the  latter  case  a  history  of  nervous  dis- 
orders— insanity,  inebriety,  or  nervous  irritability — is  gener- 
all\'  obtained.  The  disease,  which  is  apt  to  appear  between 
the  fifth  and  fifteenth  years,  rarely  as  late  as  the  twentieth 
year,  is  one  of  defective  development.  Synioiyni :  Fried- 
reich's ataxia. 

Pathology. — There  is  extensive  sclerosis  of  the  posterior 
and  lateral  columns  of  the  cord ;  this  sclerosis  may  extend 
upwards  to  involve  the  medulla. 

Symptoms, — Ataxia  is  first  developed  in  the  legs,  but 
the  gait  differs  from  that  of  locomotor  ataxia  in  being  more 
swaying  and  irregular  and  less  stamping.  Romberg's  symp- 
tom may  or  may  not  be  present,  and  the  reflexes  may  be 
preserved.  Ataxia  appears  in  the  arms,  giving  rise  to  irreg- 
ular choreiform  movements.  Rhythmical  movements  may 
also  be  observed  during  rest.  Nystagmus  and  slow,  scan- 
ning speech  are  commonly  observed,  but  visceral  symptoms 
and  optic  atrophy  are  uncommon.  Trophic  changes  are  not 
observed.  There  is  a  fairly  characteristic  deformity  of  the 
foot ;  the  patient  walks  on  the  outer  edge  of  the  foot, 
the  big  toe  is  flexed  dorsally  upon  the  first  phalanx,  and 
talipes  cquinus  is  developed.  There  are  no  sensory  symp- 
toms. The  mind  becomes  impaired  late  in  the  disease. 
As  the  disease  progresses  paralysis  appears ;  this  paralysis 
may  become  complete. 


MYKUrfS,    ACUTE  AND    CHRONIC.  743 

Prognosis. — The  disease  is  incurable,  but  its  course  ex- 
tends over  years. 

Treatment  is  unavailing. 

ATAXIC    PARAPLEGIA. 

Etiology. — Males  of  middle  age  are  most  frequently 
affected.  There  may  be  a  history  of  exposure  to  cold  or 
of  sexual  excesses,  but  antecedent  syphilis  is  rarely  to  be 
demonstrated. 

Pathology. — The  lesion  consists  of  a  combined  sclerosis 
of  the  posterior  and  lateral  columns,  beginning  in  the  lum- 
bar region.  The  nerve-roots  are  not  involved  as  in  loco- 
motor ataxia. 

Symptoms. — There  are  slowly  developing  weakness  and 
rigidity  of  the  legs,  with  ataxia.  The  knee-jerk  is  exag- 
gerated, and  ankle-clonus  can  easily  be  obtained.  The 
Romberg  symptom  is  generally  well  marked.  A  dull, 
aching  pain  in  the  sacral  region  is  the  only  sensory  symp- 
tom of  importance.  Eye-symptoms  are  rare.  The  ataxia 
and  weakness  may  extend  to  the  arms,  and  in  many  cases 
there  may  be  developed  mental  symptoms  resembling  those 
of  general  paresis.  The  muscular  weakness  ultimately 
merges  into  paralysis. 

Prognosis. — The  disease  is  incurable.  Death  results 
from  complications  rather  than   from  the  disease  itself 

The  treatment  is  that  of  chronic  myelitis. 

MYELITIS,    ACUTE    AND    CHRONIC. 

Etiology.^-Myelitis  may  occur  (i)  from  excessive  physi- 
cal exertion,  from  exposure  to  wet  and  cold,  or  from  sexual 
excesses ;  (2)  from  injury  or  disease  of  the  vertebral  bones 
causing  compression  or  destruction  of  the  spinal  cord,  or 
from  tumors  of  the  cord  itself;  (3)  from  acute  infectious 
diseases,  especially  small-pox,  measles,  and  tj^phus.  fever ; 
(4)  syphilis  as  an  exciting  or  predisposing  cause  of  myelitis 
is  questionable. 

Pathology. — The  affected  area  of  the  cord  feels  soft  and 
may  even  be  diffluent.  The  softened  area  may  be  grayish 
or  reddish  in  color  ("  red"  or  "  gray  softening  ")  according  to 


744        M.lXrAL    OF  THE  PKACT/CI-:    OF  MEDICIXE. 

whether  or  not  small  hemorrhages  into  the  cord-substance 
have  occurred.  The  nerve  cells  and  fibres  swell,  under>^o 
fatty  degeneration,  and  the  nn-elin  oozes  out  as  fatty  drop- 
lets. Large  numbers  of  inflammatorx-  corpuscles  are  every- 
where present,  and  "  Deiters'  spider-cells,"  due  to  prolifera- 
tion of  the  neuroglia,  are  to  be  seen.  The  laminated  bodies 
known  as  "  corpora  amylacea  "  are  also  present.  The  blood- 
vessels are  dilated  and  may  rupture.  The  meninges  may 
also  be  involved.  After  a  time  conservative  changes  assert 
themselves.  The  area  becomes  firm  from  an  increase  of 
connective  tissue,  so  that  the  cord  at  the  affected  point  be- 
comes converted  to  a  mass  of  cicatricial  tissue  containing 
perhaps  a  few  nerve-fibres  and  cells.  To  this  condition  the 
name  of  "  chronic  myelitis  "  is  applied. 

Secondary  degenerations  result  (i)  in  the  lateral  columns 
below  the  lesion,  and  (2)  in  the  posterior  column  and  direct 
cerebellar  tract  above  the  lesion. 

The  affected  area  varies.  In  general  myelitis  the  cord  is 
involved  along  its  entire  length  ;  in  disseminated  myelitis 
various  segments  of  the  cord  at  different  levels  are  affected  ; 
in  transverse  myelitis  one  or  two  segments  of  the  cord  at 
one  level  are  destroyed. 

The  effects  of  a  transverse  lesion  of  the  cord  are — 
(i)  Voluntary  motion  is  cut  off  from  the  parts  below  the 
lesion — paralysis.  (2)  Sensation  is  cut  off  from  the  parts 
below — anaesthesia.  (3)  Inhibitory  fibres  from  the  motor 
cortex  checking  over-reflexes  are  destroyed  at  the  site  of 
the  lesion — increased  reflexes.  (4)  The  nutrition  of  the 
parts  supplied  directly  from  the  affected  area  is  impaired, 
atrophic  changes  resulting  in  nerve,  muscle,  and  skin. 

Symptoms. — Four  stages  are  described:  (i)  A  stage  of 
premonition,  (2)  one  of  irritation,  (3)  one  of  destruction, 
and  (4)  one  of  descending  degeneration. 

I.  Prcnionitory  Stage. — There  may  be  peculiar  sensations 
in  the  parts  afterward  to  be  more  seriously  affected,  and 
motor  weakness  may  be  noticed.  There  may  be  the 
"  girdle  sensation  "  of  a  string  tied  about  the  waist,  from 
irritation  of  the  nerves  at  the  upper  level  of  the  lesion.     In 


MYELITIS,    ACUTE  AND    CHRONIC.  745 

Other  cases  these   symi)toms  are  absent,  or  there  may  be 
only  a  chill  and  fever. 

2.  The  irritative  stai^c  is  of  short  duration.  Sensory 
symptoms  consist  of  hyperctsthesia  and  neuralgic  pains 
below  the  lesion,  and  the  girdle-sensation.  Pain  in  the 
back  is  uncommon  unless  the  meninges  become  inflamed. 
The  sensory  symptoms  of  irritation  soon  become  admixed 
with  those  of  destruction,  and  feelings  of  numbness  and 
areas  of  anaesthesia  appear.  The  motor  symptoms  consist 
of  twitchings,  cramps,  and  spasms,  combined  with  some  loss 
of  voluntary  power.  The  duration  of  this  stage  varies  from 
several  hours  to  one  or  two  days. 

3.  Stage  of  Destruction. — Two  groups  of  symptoms  are 
recognized — one,  direct,  due  to  the  destruction  of  cord- 
tissue,  and  one,  indirect,  due  to  the  cutting  off  of  impulses  to 
and  from  the  brain. 

Direct  symptoms  are  observed  in  the  parts  supplied 
directly  from  the  affected  segments.  There  is  muscular 
paralysis,  with  atrophy  and  the  reaction  of  degeneration. 
Reflexes  are  lost.  There  is  anaesthesia  of  the  skin  supplied 
by  the  affected  spinal  nerves,  with  vaso-motor  symptoms 
(coldness,  sweating)  and  atrophic  changes,  as  bed-sores. 
The  atrophic  bed-sore's  are  deep  and  gangrenous.  The 
distribution  of  the  direct  symptoms  depends  upon  the 
extent  of  the  lesion.  In  general  myelitis  they  are  universal : 
if  disseminated,  they  are  scattered ;  if  transverse,  they  are 
limited  to  one  level,  the  arms  being  involved  in  cervical 
myelitis,  the  trunk  in  dorsal  myelitis,  the  legs  if  the  myelitis 
involve  the  lumbar  enlargement. 

Indirect  symptoms  result  from  the  severance  of  the  motor 
pyramidal  and  the  sensory  fibres  at  the  site  of  the  lesion. 

Below  the  lesion  there  is  paralysis,  with  increased  reflexes 
and  muscular  rigidity.  The  paralyzed  muscles  do  not 
atrophy,  and  there  is  no  reaction  of  degeneration.  If  the 
myelitis  involve  the  lumbar  enlargement,  direct  symptoms 
may  be  present  in  the  legs — paralysis,  atrophy,  loss  of 
reflexes,  and  the  reaction  of  degeneration. 

If  the  reflex  centre  for  the  bladder  be  destroyed,  the  bladder 
will  no  longer  contract  to  expel  its  contents,  but  there  will  be 


746        M.lXr.-lL    Of   THE  rRACTICE    OF  MEDICINE. 

incontinence  from  over-distention.  Usually,  however,  the 
lesion  is  higher  up  than  this,  so  that  the  reflex  bladder- 
centre  is  still  intact;  there  will  then  be  reflex  and  uncon- 
scious passage  of  urine.  The  danger  of  cystitis  threatens 
every  case  of  myelitis.  The  functions  of  the  rectum  are 
similarh'  affected. 

There  is  regularly  anrtsthesia  below  the  lesion.  The  imper- 
fect sensation  allows  of  the  formation  of  bed-sores,  from  pres- 
sure or  from  dirt,  over  the  sacrum,  the  glutei,  or  the  heels. 
These  pressure  bed-sores  are  at  first  superficial,  and  can 
be  prevented  by  careful  nursing.  The  atrophic  bed-sores 
in  areas  of  skin  supplied  by  nerves  from  the  destroyed  seg- 
ment cannot  be  prevented,  and  the}^  are  large,  deep,  and 
gangrenous. 

Cerebral  s)Mnptonis  are  rare.  There  ma\'  be  optic  neur- 
itis with  blindness.  The  pulse  varies  from  100  to  140;  the 
temperature  varies  between  102°  and  104°  F.  The  fever 
quickly  subsides  unless  cystitis,  pyelitis,  or  acute  atrophic 
bed-sores  develop.  During  this  stage  the  patient  may  die 
from  paralysis  of  the  respiratory  muscles,  pneumonia, 
cystitis,  pyelitis,  suppurative  nephritis,  or  acute  atrophic 
bed-sores.  The  majority  of  patients,  however,  pass  into 
the  stage  of  descending  degeneration,  or  "  chronic  myelitis." 

4.  Stage  of  Descending  Degeneration. — In  a  few  cases 
some  motor  power  is  regained  and  some  sensations  are  per- 
ceived, so  that  the  patient  is  able  to  get  about  on  crutches, 
although  with  spastic  paraplegia  and  loss  of  bladder- 
control.  In  other  cases  no  improvement  is  noted,  and  the 
patient  remains  bedridden,  with  parah'zed,  twitching  limbs 
and  cystitis.  Pain  in  the  back  develops  in  the  majority  of 
cases,  from  the  occurrence  of  chronic  meningitis.  Death 
results  from  suppurative  nephritis,  pneumonia,  or  bed-sores. 

Prognosis. — In  very  acute  cases  death  may  result  in  five 
or  ten  days.  Transverse  myelitis  in  the  cervical  region  is 
usually  fatal  from  paralysis  of  the  respiratory  muscles.  The 
majority  of  cases,  however,  pass  into  the  chronic  condition 
of  spastic  paraplegia,  from  which  but  trifling  improvement 
can  be  expected. 

Treatment. —  During  the  earlier  stages  the  patient  should 


ACUTE  ASCENDING  PARAL  YSIS.  747 

lie  upon  the  side  or  face  while  the  spine  is  cupped  or  is 
covered  with  a  Chapman  ice-bag.  Active  purgation  by 
calomel  or  salts  is  indicated  at  the  onset.  Ergot  in  large 
doses  has  been  recommended,  but  not  too  much  is  to  be 
expected  from  its  use.  Morphine  may  be  necessary  for  the 
relief  of  the  pain.  Great  care  should  be  exercised  to 
prevent  bed-sores  and  cystitis.  The  sheets  should  be 
drawn  smooth,  without  wrinkles,  and  should  be  kept  free 
from  crumbs.  The  skin  of  the  back  is  best  hardened  by 
daily  frictions  with  alcohol  and  alum-water.  The  bed 
should  also  be  kept  dry,  pads  of  absorbent  cotton  or  a  urinal 
being  placed  in  position  for  the  incontinence  of  the  urine. 
Carefully  padding  the  patient  with  small  pillows  may  pre- 
vent a  bed-sore,  should  a  pressure-point  become  red  and 
chafed,  while  in  many  cases  a  water-bed  is  indispensable. 
When  bed-sores  occur,  simple  antiseptic  dressings  are  indi- 
cated. For  the  prevention  of  cystitis  the  urine  should  be 
drawn  at  regular  intervals.  The  catheters  should  be  kept 
surgically  clean.  If  cystitis  develop,  the  bladder  should  be 
washed  out  daily  with  a  boric-acid  solution  (.5j  :  Oj). 

For  the  chronic  condition  counter-irritation  of  the  spine 
has  been  advised,  but  blistering  agents  should  never  be 
used,  as  there  is  danger  of  bed-sores  developing.  Spasm 
of  the  limbs  is  relieved  by  heat  to  the  spine  or  by  general 
hot  baths.  Massage  is  indicated  to  keep  up  the  nutrition 
of  the  muscles.  Drugs  are  of  no  value  in  myelitis.  Potas- 
sium iodide  and  mercury  may  be  given  to  syphilitic  subjects, 
and  phosphorus  and  arsenic  may  be  employed  as  nerve- 
tonics.  Nitrate  of  silver  (gr.  ^)  is  often  recommended. 
Strychnine  is  contraindicated  if  spasm  exist  in  the  paralyzed 
muscles. 

ACUTE    ASCENDING   PARALYSIS. 

Etiology  and  Synonym. — The  disease  is  most  common 
in  men  between  the  ages  of  twenty  and  thirty.  Some  cases 
have  followed  infectious  fevers.  Synonym :  Landry's  paralysis. 

Pathology. — In  many  of  the  cases  an  interstitial  neuritis 
of  the  nerve-roots  has  been  demonstrated,  so  that  the 
disease  has  been  classed-  as  a  peripheral  neuritis.     In  other 


74 S        M.IXCAL    OF  THE  PKACriCE    OF  MEDICIXE. 

cases,  however,  no  lesions  have  been  found,  so  that  it  is 
supposed  that  the  paralysis  is  due  to  some  form  of  microbic 
poisoning.  The  disease  bears  a  close  resemblance  to  para- 
lytic rabies. 

Symptoms. — Weakness  in  the  legs  merges  within  a  few 
hours  into  parah'sis,  wliich  spreads  to  involve  the  trunk, 
arms,  and  neck.  Finally  the  muscles  of  respiration,  deglu- 
tition, and  articulation  become  affected,  and  there  may  be 
facial  and  eye-palsies.  The  reflexes  are  lost,  but  the  mus- 
cles neither  waste  nor  show  the  electrical  reactions  of  de- 
generation. There  may  be  numbness,  tingling,  or  hyperaes- 
thesia,  but  sensory  symptoms  are  neither  constant  nor 
essential.  The  bladder  and  rectum  are  seldom  involved. 
Febrile  reaction   is  trifling. 

Prognosis. — Death  may  result  within  two  da\'s  or  may 
be  postponed  for  one  or  two  weeks.  Recovery  has  occurred 
onh'  in  rare  instances. 

Treatment. — Ergotin  in  2-grain  doses  may  be  given 
every  hour,  and  success  has  followed  its  administration; 
sodium  salicylate  and  benzoate  also  have  been  recom- 
mended ;  otherwise  the  treatment  is  symptomatic. 

SYRINGO-MYELIA. 

Etiology. — This  rare  disease  is  probably  of  congenital 
origin.  Its  exact  cause  is  unknown.  The  symptoms 
usualh'  appear  in  males  between  the  ages  of  fifteen  and 
twent\'-five. 

Pathology. — There  is  a  development  of  embryonal  neur- 
oglia-tissue  about  the  central  canal  of  the  spinal  cord  ex- 
tending to  involve  the  entire  central  gray  matter.  Degen- 
eration and  liquefaction  result  in  the  formation  in  the  spinal 
cord  of  a  cavity  filled  with  cerebro-spinal  fluid ;  the  walls 
of  the  cavity  are  composed  of  gliomatous  tissues.  The 
usual  situation  is  in  the  lower  cervical  and  upper  dorsal 
region.  In  other  cases  the  cavity  extends  the  entire  length 
of  the  spinal  cord.  The  cavity  may  invade  the  anterior 
horns,  causing  the  symptoms  of  chronic  anterior  polio- 
myelitis, or  may  invade  the  posterior  horns  and  columns, 
causing  the  symptoms  of  posterior  sclerosis. 


COMPRESSION-M  YKr.rflS.  'JA,<J 

The  symptoms  begin  insidiously  about  the  time  of 
adolescence,  and  extend  over  years.  There  are  aching 
pains  in  the  neck  and  the  arms,  followed  by  muscular 
atrophy,  first  in  the  hands,  then  in  the  arms  and  trunk. 
There  is  a  loss  of  the  sensations  of  temperature  and 
pain,  but  the  touch-sensations  remain  intact — a  form  of 
partial  anaesthesia  which  is  almost  pathognomonic.  The 
legs  become  involved  late  in  the  disease,  and  show  the 
symptoms  of  spastic  paraplegia.  From  the  involvement  of 
the  spinal  muscles,  curvature  (scoliosis)  almost  regularly 
results.  Vaso-motor,  secretory,  and  trophic  symptoms  are 
common  in  the  affected  parts — cyanosis,  oedema,  sweating, 
ulcers,  bullae,  defective  growth  of  the  nails,  brittleness  of 
the  bones.  Felons  are  common.  There  is  loss  of  control 
over  the  bladder  and  rectum  if  the  lumbar  region  of  the 
cord  be  involved. 

The  prognosis  is  bad,  although  the  disease  extends  over 
years.  The  latter  stages  of  the  disease  resemble  chronic 
muscular  atrophy.  Death  may  result  from  involvement  of 
the  medulla. 

Treatment  is  inoperative.  Arsenic  and  nitrate  of  silver 
are  generally  given  as  a  routine,  but  beneficial  results  are 
not  to  be  expected  from  medication. 

COMPRESSION-MYELITIS  (SLOW  COMPRESSION 
OP  THE  CORD). 

Etiology. — The  spinal  cord  may  be  compressed  {a)  by 
disease  of  the  vertebral  bones,  especially  caries ;  {6)  by 
thickened  membranes  ;  [c)  by  tumors  of  the  cord,  mem- 
branes, or  bones.  The  most  common  tumors  are  carcinoma, 
(usually  secondary  to  primary  growths  in  the  breast),  retro- 
peritoneal sarcoma  and  aneurysm  (causing  erosion  of  the 
bodies  of  the  vertebrae,  so  that  they  come  to  lie  directly  on 
the  spinal  cord  itself),  and  sarcoma  of  the  membranes. 

The  pathology  is  that  of  a  pressure-atrophy. 

The  symptoms  are  those  of  chronic  myelitis  slowly 
developing  with  a  prolonged  stage  of  irritation. 

Compression  of  the  spinal-nerve-roots  causes  neuralgic 
pains  with  areas  of  anaesthesia  ("  anaesthesia  dolorosa  ")  and 


75-        MAXr.lL    OF   THE   PRACTICE    OF  MEDIC IXE. 

with  muscular  spasms  followed  by  paralysis,  loss  of  reflexes, 
and  atrophy  of  muscle. 

Compression  on  a  spinal  segment  gives  rise  to  anaesthesia, 
paralysis,  atrophy,  loss  of  reflexes,  and  the  reaction  of  de- 
generation in  the  muscles  supplied  directly  from  the  com- 
pressed segment.  Below  the  affected  segment  there  are  the 
symptoms  of  spastic  paraplegia — paralysis,  increased  re- 
flexes, absence  of  atrophy  and  of  the  reaction  of  degenera- 
tion. There  is  loss  of  bladder-  and  rectum-control.  If  the 
compressed  segment  be  in  the  lower  dorsal  and  lumbar 
regions,  the  reflexes  in  the  legs  will  be  lost  and  the  muscles 
will  atrophy. 

The  prognosis  depends  upon  the  cause  of  the  com- 
pression. 

Treatment  is  that  of  the  original  cause.  Caries  of  the 
vertebrae  is  best  treated  by  suspension.  Tumors  may  be 
removed  by  operation  if  it  be  practicable.  In  some  cases 
of  bone  disease  laminectomy  may  be  performed  with 
benefit. 

TUMORS  OF   THE    SPINAL  CORD. 

Etiology  and  Pathology. — Tumors  of  the  spinal  cord  are 
rare  and  are  usually  secondary  to  growths  elsewhere.  Sar- 
coma and  tubercular,  syphilitic,  and  gliomatous  growths  are 
most  frequently  observed.  The  compression  of  the  spinal 
cord  leads  to  a  chronic  myelitis  at  the  seat  of  the  growth, 
and  in  rare  cases  may  induce  the  condition  of  syringo- 
myelia. 

Symptoms. — The  symptoms  arc  those  of  a  compression- 
myelitis  or  of  Brown-Sequard's  paralysis,  of  slow  develop- 
ment and  characterized  by  such  extreme  pain  in  the  sensory 
areas  corresponding  to  the  segment  in  which  the  tumor 
grows  that  the  name  "paraplegia  dolorosa"  has  frequently 
been  applied. 

The  prognosis  is  bad  in  inoperable  growths. 

The  treatment  is  to  remove  the  tumor  if  possible;  other- 
wise the  treatment  is  symptomatic. 


DISEASES   OF   T//E    0PTIC  NERVE. 


751 


BROWN-SEQUARD'S    PARALYSIS. 

Etiology. — One  half  of  the  spinal  cord  may  be  destroyed 
by  tumors,  by  hemorrhages,  by  disease  of  the  vertebral 
bones,  or  by  traumatism. 

The  pathology  is  that  of  a  destructive  lesion  involving 
a  lateral  half  of  a  spinal  segment. 

The  symptoms  are  best  appreciated  by  consulting  the 
following  table  of  Gowers : 

Cord. 


Zone  of  cutaneous  hyperaesthesia. 
Zone  of  cutaneous  anaesthesia. 


Motor  palsy. 
Hyperaesthesia  of  skin. 
Muscular  sense  impaired. 
Reflex  action  at  first  lessened, 

then  increased. 
Temperature  raised. 


Muscular  power  normal. 
Loss  of  sensibility  of  skin. 
Muscular  sense  normal. 
Reflex  action  normal. 

Temperature  same  as  that  above 
the  lesion. 


Treatment  is  directed  to  the  cause  of  the  hemi-lesion ; 
otherwise  the  treatment  is  that  of  myelitis. 


5.  DISEASES  OF  THE  CRANIAL  NERVES. 

OLFACTORY  NERVE. 

Anosmia,  or  loss  of  the  sense  of  smell,  may  occur  with 
chronic  nasal  catarrh  or  with  diseases  of  the  olfactory 
nerves  or  bulbs  following  meningitis,  frontal  tumors,  or 
caries  of  the  bones.  The  symptom  is  not  uncommon 
among  insane  and  hysterical  patients. 

Hyperosmia,  or  increased  sensitiveness,  and  parosmia,  or 
subjective  perversions,  of  the  sense  of  smell,  are  not  infre- 
quently observed  in  neurotic  patients.  Parosmia  may  pre- 
cede an  attack  of  epilepsy. 

OPTIC  NERVE. 
Many  of  the  diseases  of  the  optic  nerve  clearly  belong 
to  the  domain  of  ophthalmology,  and  therefore  will  not  be 
considered  here. 


752         MAXCAI.    OF   THE   PRACTICE    OF  MEDICINE. 

Destructive  lesions  in  various  parts  of  the  optic,  tract 
produce  the  followinf^  results  (see  Fig.  59) : 

1.  Lesions  of  the  optic  nerve  produce  blindness  of  the 
corresponding  e\e. 

2.  Lesions  of  the  chiasm  may  produce  blindness  of  both 
eyes  (if  the  chiasm  be  totally  destroyed),  temporal  hemiano- 
pia  (if  the  central  part  of  the  chiasm  be  involved),  or  nasal 
hemianopia  (if  both  lateral  regions  of  the  chiasm  be  affected). 

3.  Lesions  of  the  optic  tract  produce  lateral  hemianopia. 

4.  Lesions  of  the  cuneus  produce  lateral  hemianopia. 

5.  Lesions  of  the  angular  gyrus  give  rise  to  hemianopia 
and  mind-blindness,  rarely  to  crossed  amblyopia. 

Hemianopia,  though  usually  of  organic  origin,  may  occur 
with  hysteria,  migraine,  and  lithairnia.  In  hemianopia,  if 
the  pupil  reacts  when  a  ray  of  light  is  thrown  upon  the 
sensitive  half  of  the  retina,  the  lesion  is  in  the  optic  radia- 
tion or  in  the  cerebral  cortex. 

THIRD  NERVE. 

Nuclear  lesions  of  the  third  nerve  are  usually  associated 
with  disease  of  the  other  ocular-nerve-centres  (see  Oph- 
thalmoplegia). Disease  of  the  third-nerve-trunk  is  not 
uncommon.  The  nerve  may  be  the  seat  of  a  neuritis  (espe- 
cially with  locomotor  ataxia  and  after  diphtheria),  it  may  be 
compressed  by  meningitis,  tumors,  or  aneurysms  at  the  base 
of  the  brain,  or  it  may  be  paralyzed  from  exposure  to  cold, 
from  rheumatism,  from  syphilis,  or  by  an  attack  of  mi- 
graine. Paralysis  of  the  third  nerve  gives  rise  to  external 
strabismus,  ptosis,  dilatation  of  the  pupil,  loss  of  pupil-reflex 
and  of  accommodation  to  distance,  and  to  diplopia,  or 
double  vision. 

A  form  of  oculo-motor  palsy  is  described  as  occurring 
chiefly  in  women,  and  as  recurring  at  intervals  of  several 
months,  associated  with  pain  and  migraine. 

Spasm  of  the  muscles  supplied  by  the  third  nerve  is  not 
uncommon  in  meningitis  and  in  hysteria.  Slow  rhythmical 
oscillations  of  both  eyeballs  (nystagmus)  occur  in  congenital 
and  acquired  brain  affections  and  in  albinism,  and  is  not 
uncommon  among  coal-miners. 


DISEASES    OE   77/E    /'//'77/  NE/x'VE.  753 

FOURTH   NERVE. 

The  causes  of  fourth-nerve-paralysis  are  similar  to  those 
causing  third-ncrve-palsy.  The  symptoms  are  a  slight  con- 
vergent strabismus  when  the  eye  is  rolled  downward,  and 
double  vision  when  the  patient  looks  down, 

FIFTH  NERVE. 

Paralysis. — The  nucleus  may  be  involved  by  hemor- 
rhages or  tumors  of  the  pons,  or  the  branches  of  the  nerve 
may  be  affected  within  the  cranium  by  meningitis,  caries, 
or  tumors.  The  lower  divisions  are  not  infrequently  in- 
volved by  tumors  of  the  upper  jaw.  Primary  neuritis  is 
rare. 

Symptoms. — Sensory .-—Y\\qxq  is  anaesthesia  of  the  skin 
of  the  face  and  head,  the  conjunctiva,  and  the  mucosa  of  the 
lips,  tongue,  soft  and  hard  palate,  and  nose.  The  anaesthe- 
sia may  be  preceded  by  hyperaesthesia  or  by  tingling  feel- 
ings. 

Motor. — The  temporal  and  masseter  muscles  are  paralyzed, 
and  the  jaw,  when  depressed,  moves  toward  the  paralyzed 
side.  The  motor  palsy  is  usually  due  to  lesions  involving 
the  trunk  of  the  nerves. 

Trophic  and  Vaso-motor  Changes. — There  may  be  ulcera- 
tions of  the  mucosa,  falling  of  the  teeth,  opacity  and  ulcera- 
tion of  the  cornea,  diminished  salivary,  nasal,  buccal,  and 
lachrymal  secretions,  flushings  and  pallor,  and  herpes.  The 
trophic  changes  occur  if  the  Gasserian  ganglion  is  affected. 

Gustatory. — There  is  regularly  loss  of  the  sense  of  taste 
in  the  anterior  two-thirds  of  the  tongue. 

Spasm  of  the  M^iscles  of  Mastication  (Trismus ;  Lock- 
jaw).— Trismus  occurs  with  tetanus,  tetany,  and  hysteria, 
from  reflex  irritation  from  diseases  of  the  teeth  and  jaws, 
and  from  irritation  of  the  motor  nucleus  of  the  fifth  nerve. 
Trismus  nascentium  is  caused  by  infection  through  the  um- 
bilicus of  newly-born  children.  The  spasm  may  be  tonic  or 
clonic.     Clonic  spasms  may  occur  as  a  symptom  of  chorea. 

Neuralgia    (Tic    Douloureux). — Neuralgia    of    all    the 

48 


754      ^i/.i.yc.iL  OJ-'  THE  PKAcricE  of  medicixe. 

branches  of  the  fifth  nerve  is  rare ;  usually  the  ophthalmic, 
alone  or  with  the  superior  maxillary  division,  is  affected. 

For  the  etiology  of  neuralgia  see  the  article  on  Neuralgia. 

Supmorhital  ucuralgia  is  marked  by  shooting  pains 
along  the  course  of  the  nerves,  b\-  painful  spots  at  the 
supraorbital  notch,  at  the  inner  angle  of  the  orbit,  and  at 
the  junction  of  the  bone  and  cartilage  of  the  nose.  There 
are  usually  intolerance  to  light,  injection  of  the  conjunctiva, 
and  increased  lachrymation.  The  skin  may  be  exquisitely 
tender  to  the  touch.  In  severe  cases  there  may  be  painful 
spasm  of  the  facial  muscles  (spasmodic  tic).  In  protracted 
cases  the  hair  on  the  affected  side  may  become  gray. 

Superior  Maxil/ary  Neuralgia. — Pain  is  referred  to  the 
teeth  of  the  upper  jaw,  and  a  painful  point  is  located  at  the 
infraorbital  foramen. 

Inferior  Maxillary  Neuralgia. — The  pain  is  experienced 
about  the  ear  and  \\\  the  teeth  of  the  lower  jaw,  and  painful 
spots  may  be  elicited  along  the  auriculo-temporal  nerve. 

The  treatment  of  neuralgia  will  be  considered  under  a 
separate  heading  (see  page  775). 

SIXTH  NERVE. 
Abducens  palsy  occurs  most  commonly  with  syphilis  and 
locomotor  ataxia,  and  causes  convergent  strabismus,  double 
vision,  and  inability  to  rotate  the  eye  outward.  When  the 
nucleus  of  the  nerve  is  involved,  there  is,  in  addition  to  the 
paralysis  of  the  external  rectus,  an  inability  of  the  internal 
rectus  of  the  unaffected  eye  to  turn  that  eye  inward.  Both 
eyes  are  therefore  deviated  to  the  opposite  side,  away  from 
the  lesion  (conjugate  deviation). 

SEVENTH  NERVE— FACIAL. 

Facial  Paralysis  (Bell's  Palsy). — The  innervating  fibres 
of  the  facial  muscles  may  be  paralyzed  (i)  above  the 
nucleus,  (2)  at  the  nucleus,  or  (3)  after  leaving  the  nucleus. 

I.  Supranuclear  paralysis  is  caused  by  destructive  lesions 
of  the  cortex,  corona  radiata,  and  internal  capsule,  and  is, 
as  a  rule,  accompanied  by  hemiplegia  on  the  same  side  as 
the  facial  paralysis.     Facial  paralysis  alone  from  cortical  or 


DISEASES   OF   THE   SEVENTH  NERVE.  755 

central  lesions  is  uncommon.  Supranuclear  paralysis  differs 
from  the  peripheral  form  in  that  the  electrical  reactions  of 
the  affected  muscles  remain  normal,  and  the  upper  branches 
of  the  facial  nerve  are  not  involved,  so  that  the  patient  can 
wink  and  can  corrugate  the  forehead. 

2.  Nuclear  paralysis  is  uncommon.  The  nucleus  may  be 
involved  by  tumors,  by  hemorrhages,  or  by  softening,  or 
with  diphtlieria  or  anterior  poliomyelitis.  The  symptoms 
are  the  same  as  those  of  the  peripheral  type.  Lesions  of 
the  pons  may  cause  facial  paralysis  on  the  same  side,  and 
crossed  hemiplegia,  the  so-called  "  crossed  facial  paralysis  " 
(See  Fig.  61). 

3.  Peripheral  or  Iiifrannclear  Paralysis. — The  nerve-trunk 
may  be  involved  (a)  within  the  pons,  by  hemorrhage,  tumor, 
or  softening,  with  the  production  of  crossed  facial  paralysis ; 
{f)  at  its  point  of  emergence,  by  tumors,  meningitis,  syphilis, 
or  fractures  at  the  base  of  the  skull ;  [c)  in  the  Fallopian 
canal,  by  diseases  of  the  middle  ear  or  by  caries  of  the 
petrous  portion  of  the  temporal  bone;  {d^  at  its  emergence 
through  the  styloid  foramen,  by  blows,  cuts,  tumors  of  the 
parotid  gland,  or  by  the  pressure  of  the  forceps  in  instru- 
mental delivery ;  {c)  exposure  to  cold  is  a  frequent  cause 
leading  to  a  mild  form  of  neuritis. 

Symptoms. — In  peripheral  facial  paralysis  all  the 
branches  of  the  nerve  are  usually  affected.  The  expression 
of  the  face  is  striking  and  characteristic.  The  paralyzed 
half  of  the  face  is  lax,  wrinkles  are  obliterated,  and  the 
naso-labial  fold  is  no  longer  evident.  The  lower  lid  droops, 
the  eye  waters,  and  the  eye  cannot  be  closed  voluntarily. 
The  corner  of  the  mouth  sags,  the  mouth  is  drawn  away 
from  the  affected  side,  and  there  is  constant  drooling  of 
saliva.     Mastication  and  articulation  become  impaired. 

In  many  cases  there  is  said  to  be  a  paralysis  of  the  soft 
palate,  but  this  is  doubted  by  Gowers.  Facial  paralysis  is 
rendered  evident  by  any  attempt  at  talking,  whistling,  or 
inflating  the  cheeks.  The  exact  localization  of  the  lesion 
can  readily  be  appreciated  by  an  examination  of  the  accom- 
panying diagram  (Fig.  67). 

I.  Paralysis  of  facial  muscles;  taste,  secretion  of  saliva, 


756 


MAXr.lL    OF   THE   PRACTICE    OF  MEDIC  EYE. 


and  hearing  are  normal ;  the  seat  of  the  affection  is  in  the 

portion  between  i  and  2,  usually  in  the  trunk  of  the  facial 

ner\'e,  below  the  Fallopian  canal. 

2.  Parah'sis  of  the  facial  muscles,  disturbance  of  taste, 

and    eventually    diminished    secretion     of    saliva ;    hearing 

normal ;  the  seat  of  the 
lesion  is  in  the  Fallopian 
canal,  between  2  and  3. 

3.  Paralysis  of  the  facial 
muscles,  disturbance  of 
taste,  diminished  secretion 
of  saliva,  abnormal  acute- 
ness  of  hearing;  the  seat 
of  the  lesion  is  between 
3  and  4. 

4.  Paralysis  of  the  facial 
muscles,  disturbance  of 
taste,  diminished  secretion 
of  saliva,  abnormal  acute- 
ness  of  hearing,  and  par- 
esis of  the  soft  palate  (?) ; 
the  seat  of  the  lesion  is  in 

Fig.  67.— Schematic  representation  of  the  trunk  the  gCniculatC  ganglion, 
of  the  facial  from  the  base  of  the  skull  to  the  pes 
anserinus;  different  localizations  of  the  lesion  in 
paralysis  (Striimpell)  :  N./.,  facial  nerve;  N.p.s., 
great  superficial  petrosal;  N.c.c.p.t.,  nerve  com- 
municating with  the  tympanic  plexus;  N.st., 
stapedius;  a.^,  chorda  tympani;  G./.,  fibres  of  ^j^^  ^f  ^^\^^^  abnormal 
taste;    S.p.s.,   nerve   governing   the   secretion   of 

saliva;    N.a.,   acoustic    nerve:     G.».,   geniculate     aCUtCnCSS   of   hearing,  par- 
ganglion;   F.st     stylo-mastoid   foramen;    N.a.p.,     ^^j^        j-  ^^^^  .^^^  ^pX     |^^j^ 

posterior  auricular  nerve.  i  v    /' 

no  disturbance  of  taste ; 
the  seat  of  the  lesion  is  above  the  geniculate  ganglion, 
between  5   and  6. 

Erb  distinguishes  three  grades  of  severity  of  facial 
paralysis : 

I.  Mild  Form. — This  form  usually  occurs  after  exposure 
to  cold.  The  facial  muscles  are  alone  involved,  there  being 
no  acuteness  of  hearing  nor  disturbance  of  taste.  Elec- 
trical reactions  remain  good,  and  recovery  follows  after  two 
or  three  weeks. 


between  4  and  5. 

5.  Paralysis  of  the  facial 
muscles,  diminished  secre- 


DISEASES    OF   'J7fK   /U/D/VOA' V  AEATF.  757 

2.  Middle  Form. — There  is  a  partial  reaction  of  degenera- 
tion. The  electrical  excitability  of  the  nerve  is  diminished, 
but  not  entirely  lost.  In  two  or  three  weeks  the  A.  C.  C. 
is  found  greater  than  the  C.  C.  C,  and  the  muscles  react 
slowly  to  the  galvanic  current.  Recovery  ensues  in  from 
four  to  eight  weeks. 

3.  Severe  Form. — There  is  loss  of  faradic  and  galvanic 
excitability  of  the  nerves ;  the  galvanic  excitability  of  the 
muscles  shows  decided  reaction  of  degeneration.  Recovery 
does  not  occur  before  eight  to  fifteen  months. 

The  prognosis  of  facial  paralysis  is  usually  good.  In 
cases  following  traumatism,  however,  the  damage  done  to 
the  nerve  may  be  permanent.  In  some  cases,  during  con- 
valescence, contractures  are  observed  in  the  affected  muscles, 
so  that  the  wrinkles  and  folds  of  the  skin  may  actually  be 
deepened  upon  the  affected  side. 

Spasm  of  the  facial  nerve  is  rare  as  the  result  of 
irritation  of  its  nucleus.  Usually  spasm  occurs  as  a  habit 
in  children  or  is  due  to  reflex  irritation.  Tonic  spasm  may 
follow  paralysis  or  may  be  due  to  catching  cold.  Facial 
spasm  may  be  part  of  the  affection  known  as  "  tic  convulsif," 
characterized  by  spasms  of  various  facial  muscles  and  by 
explosive  utterances,  frequently  of  bad  language. 

AUDITORY  NERVE. 

The  centre  for  hearing  is  in  the  first  temporal  convolution. 
Left-sided  lesions  in  this  location  give  rise  to  word-deafness. 
The  fibres  passing  from  the  cortical  centre  to  the  auditory 
nucleus  in  the  medulla  may  be  destroyed  by  tumors  of  the 
corpora  quadrigemina. 

Nuclear  degeneration  is  uncommon.  The  nerve  itself 
may  be  compressed  by  meningitis  or  by  tumors  or  fractures 
of  the  base  of  the  skull.  Neuritis  may  complicate  loco- 
motor ataxia,  and  is  not  uncommon  with  epidemic  cerebro- 
spinal meningitis,  many  cases  of  deaf-mutism  following  this 
latter  disease.  The  labyrinthine  branches  may  be  involved 
by  inflammation  extending  from  the'  middle  ear,  by  over- 
dosing by  quinine  and  the  salicylates,  and  by  the  constant 


75^        .V.l.VC.IL    ()/•'   77/Z,-   rf:ACTICE    OF  MEDICIXE. 

noises  and  jarrinf^  to  which  locomotive-makers  and  boiler- 
makers  are  subject. 

Destructive  lesions  in  the  course  of  the  auditor}'  tract 
give  rise  to  "  nervous  deafness,"  frequently  associated  with 
tinnitus  and  vertigo.  Sudden  complete  deafness  is  charac- 
teristic of  syphilitic  disease  of  the  internal   ear. 

The  diagnosis  of  nervous  deafness  from  that  produced 
by  local  disease  of  the  middle  ear  is  made  by  the  use  of 
the  tuning-fork.  If  the  vibrations  of  the  tuning-fork  are 
audible  when  the  base  of  the  instrument  is  placed  against 
the  temporal  bone,  nervous  deafness  may  be  excluded. 

Meniere's  Disease  (Auditory  Vertigo;  Labyrinthine 
Vertigo). — At  the  present  date  all  cases  of  aural  vertigo 
are  spoken  of  as  instances  of  Meniere's  disease,  but  more 
properly  the  name  should  be  restricted  to  those  cases  with 
a  sudden  onset  and  recurring  as  a  paroxysmal  affection, 
originally  described  by  Meniere  in    i86i. 

Etiology. — The  condition  is  most  common  in  males  after 
the  fortieth  year,  and  appears  to  bear  no  relation  to  middle- 
ear  disease. 

Pathology. — Whether  the  lesion  be  in  the  semicircular 
canals  or  in  the  cerebral  centres  is  not  known. 

Symptoms. — The  patient  suddenly  becomes  giddy ; 
surrounding  objects  seem  to  revolve,  or  the  patient  himself 
may  seem  to  be  gyrating,  usually  from  the  left  to  the  right. 
The  vertigo  may  render  walking,  or  even  standing,  impos- 
sible. The  onset  may  be  so  abrupt  that  the  patient  will 
fall,  and  may  even  lose  consciousness  for  a  short  time. 
In  a  few  minutes  the  dizziness  passes  away;  the  patient  is 
left  pale,  prostrated,  and  bathed  with  a  clammy  sweat,  and 
nausea  and  vomiting  are  apt  to  follow  the  attack.  There  is 
usually  deafness  in  one  ear,  never  complete. 

The  paroxysms  recur  at  irregular  intervals,  and  the 
prognosis  is  uncertain.  Recovery  occurs  in  some  cases, 
while  in  others  the  attacks  become  more  frequent  and  deaf- 
ness may  become  complete. 

Treatment. — Quinine  in  20-grain  doses  daily  for  several 
weeks  has  been  recommended  by  Charcot.  Hypodermic 
injections  of  from  5  to   lo  drops  of  a  2  per  cent,  solution 


DISEASES   OF   THE   ENEUMOGASTR IC  jVEA'VE.      759 

of  pilocarpine  every  second  day  are  often  of  service,  but 
the  treatment  should  be  restricted  to  robust  patients. 
Nitroglycerin  may  be  given  if  there  be  high  arterial  tension. 
Sodium  bromide  or  hydrobromic  acid  is  often  of  great 
service.  Sodium  salicylate  in  5-grain  doses  three  times 
daily  is  recommended  by  Gowers. 

GLOSSO-PHARYNGEAL  NERVE. 

Nuclear  degeneration  gives  rise  to  the  pharyngeal  symp- 
toms of  bulbar  paralysis.  The  nerve-trunk  may  be  in- 
volved by  meningitis,  or  may  be  the  seat  of  a  diphtheritic 
neuritis,  causing  difficulty  in  swallowing  and  loss  of  sensa- 
tion in  the  palate.  Lesions  of  the  root  of  the  glosso- 
pharyngeal nerve  do  not  give  rise  to  loss  of  taste  in  the 
posterior  third  of  the  tongue,  as  the  taste-fibres  come 
originally  from  the  fifth  nerve. 

PNEUMOGASTRIC   NERVE. 

The  vagus  gives  branches  to  the  pharynx,  larynx,  lungs, 
heart,  oesophagus,  and  stomach,  and  is  the  chief  afferent 
nerve  of  the  vaso-motor  centre.  The  nucleus  may  be  in- 
volved by  hemorrhage,  tumor,  softening,  or  by  slow  degen- 
eration as  in  bulbar  paralysis.  The  nerve-root  within  the 
cranium  may  be  compressed  by  meningitis,  by  tumors,  or 
by  aneurysm  of  the  vertebral  artery.  In  the  neck  the 
vagus  maybe  injured  by  wounds  or  maybe  accidentally  cut 
or  ligated  in  surgical  operations.  The  recurrent  laryngeal 
branches  are  frequently  stretched  by  the  growth  of  aortic 
or  innominate  aneurysms.  Neuritis  of  the  vagus  is  uncom- 
mon. 

I.  Pharyngeal  Branches. — Motor  branches  from  the 
pneumogastric  combine  with  those  from  the  glosso-pharyn- 
geal  to  form  the  pharyngeal  plexus.  Paralysis  may  result 
from  bulbar  degeneration  or  as  the  result  of  a  post-diph- 
theritic neuritis.  The  symptom  is  difficulty  in  swallowing. 
Food  may  enter  the  larynx  or  may  be  regurgitated  through 
the  nose  if  the  soft  palate  also  be  paralyzed. 

Spasm  is  usually  a  neurosis,  affecting  nervous   people. 


760 


MAXCAL    OF    THE    PRACTICE    OF  MFDICLXE. 


Its  type  is  the  "  globus  hjstericus."  Spasm  is  one  of  the 
principal  symptoms  of  hj'drophobia  and  of  pseudo-rabies. 

2.  Laryngeal  Branches. — The  superior  laryngeal  branch 
supplies-  the  mucous  membrane  of  the  larynx  above  the 
vocal  cords,  and  the  crico-thyroid  muscle.  The  recurrent 
laryngeal,  arising  in  the  upper  part  of  the  thorax,  supplies 
the  mucous  membrane  below  the  vocal  cords,  and  all  the 
muscles  except  the  cpiglottidean  and  the  crico-thyroid. 
The  motor  fibres  are  derived  originally  from  the  spinal 
accessory. 

The  following  chief  forms  of  laryngeal  paralysis  are  thus 
tabulated  by  Gowers : 


Symptoms. 

No  voice ;  no  cough  ;  stridor 
only  on  deep  inspiration. 

Voice  low-pitched      and 

hoarse ;  no  cough ;  stridor 
absent  orslighton  deep  breath- 
ing. 

Voice  little  changed;  cough 
normal;  inspiration  difficult  and 
long,  with  loud  stridor. 

Symptoms  inconclusive  ;  little 
affection  of  cough  or  voice. 

No  voice  ;  perfect  cough  ;  no 
Stridor  or  dyspnoea. 


Signs. 

I'oth  cords  moderately  ab- 
ducted and  motionless. 

One  cord  moderately  abduct- 
ed and  motionless,  the  other 
moving  freely,  and  even  beyond 
the  middle  line  in  phonation. 

Roth  cords  near  together,  and 
during  inspiration  not  separ- 
ated, but  even  drawn  together. 

One  cord  near  the  middle 
line,  not  moving  during  inspi- 
ration: the  other  cord  normal. 

Cords  normal  in  position  and 
moving  normally  in  respiration, 
but  not  brought  together  on  an 
attempt  at  phonation. 


Lesion. 
Total  bilateral  palsy. 

Total  unilateral  palsy. 
Total  abductor  palsy. 


Unilateral 
paralysis. 


abductor 


Adductor  palsy. 


The  laryngeal  palsies  may  be  due  to  nuclear  disease  (as 
bulbar  paralysis),  to  lesions  of  the  trunk  of  the  vagus  or 
of  the  recurrent  lar\'ngeal  nerves,  to  severe  lar}'ngeal 
catarrhs,  or  to  over-use  of  the  voice,  or  they  may  appear  as 
hysterical  conditions.  For  a  more  detailed  description  of 
the  laryngeal  palsies  the  reader  is  referred  to  specialized 
works  upon  the  subject. 

Spasm  of  the  laryngeal  muscles  may  occur  in  children 
(see  Laryngismus  Stridulus  and  Spasmodic  Croup),  or  in 
adults  as  a  laryngeal  crisis  of  locomotor  ataxia.  Paroxysmal 
attacks  of  lar\'ngeal  spasm  sometimes  occur  in  adults,  usually 
in  the  night;  they  have  been  known  to.  replace  migraine. 
Spasm  may  also  be  induced  by  irritation  of  the  recurrent 
laryngeal    nerve    by   the   pressure   on    it   of  aneurysms   or 


DISEASES   OF   THE   PNEUMOGASTR fC  NERVE.      761 

tumors,  the  spasmodic  dyspnoea  thus  induced  beinfr  rcHevcd 
by  whiffs  of  chloroform,  while  the  obstructive  dyspnrjea  of 
aneurysmal  pressure  on  the  trachea  or  of  paralytic  dyspnoea 
remains  unchanged.  Laryngeal  spasm  may  occur  with 
tetany  or  hysteria.  A  rare  condition  of  functional  spasm 
occurs  when  attempts  are  made  to  speak,  the  cords  being 
brought  together  too  forcibly. 

3.  Pulmonary  Branches. — The  spasmodic  contraction  of 
the  muscular  fibres  of  the  bronchial  walls  in  asthma  is 
thought  to  be  induced  by  a  neurosis  of  the  vagus.  De- 
structive lesions  of  the  nucleus  of  the  pneumogastric,  as 
hemorrhage  or  softening,  are  followed  by  rapid  congestion 
of  the  lung,  with  extravasation  of  blood  into  the  pulmonary 
tissue. 


Fig.  I 


-A,   Adductor  paralysis  of  both  cords;    b,  adductor  paralysis  of  left  cord;  c, 
abductor  paralysis  of  both  cords  (Brown). 


4.  Cardiac  branches  are  motor,  sensory,  and  trophic  in 
character. 

{a)  Motor. — Irritation  of  the  vagus  causes  an  inhibitory 
slowness  of  the  heart's  action.  Bradycardia  may  thus 
follow  irritation  of  the  vagus-nucleus  or  compression  of  the 
nerve  in  the  neck  by  tumors,  or  the  slowing  of  the  pulse 
may  be  an  evidence  of  a  pure  neurosis  of  the  nerve. 
Paralysis  of  the  vagus  abolishes  inhibitory  action  and 
allows  the  accelerators  full  sway.  Tachycardia  may  thus 
occur  with  diphtheritic  neuritis,  wounds  or  accidental  liga- 
ture of  the  vagus,  or  the  involvement  of  the  nerve-trunk 
by  tumors  or  by  toxaemic  conditions  depressing  the  activity 
of  the  vagus-nucleus. 

[li)  Sensory. — The  vagus  is  the  afferent  nerve  of  the  heart, 
and  through  it  the  unpleasant  sensations  of  palpitation  and 


■j62        M.l.yr.lL    OF   THE   PKACTICE    OF  MEDICIXE. 

pain  are  conveyed  to  the  brain.  The  relation  of  the  pneu- 
niogastric  nerve  to  angina  pectoris  is  not  thoroughly- 
understood. 

[c]  Trophic. — After  injury  of  the  vagus  the  heart  is 
usually  found  in  the  condition  of  acute  fatty  degeneration. 

5.  OESOPHAGEAL  BRANCHES. — Paralysis  of  the  oesophagus 
gives  rise  to  difficulty  in  swallowing,  simulating  stricture. 
Spasm  of  the  oesophagus  is  more  frequent  than  paralysis. 

6.  Gastric  branches  are  sensory  and  motor. 

{a)  Sensory  brandies  may  be  the  seat  of  pain,  either  from 
irritation  of  the  terminal  fibres  or  from  spontaneous  neural- 
gia. Hunger  is  generally  believed  to  be  a  pneumogastric 
sensation,  and  it  is  probable  that  many  cases  of  nervous 
dyspepsia  are  dependent  upon  deranged  functional  activity 
of  the  vagus  nerve. 

ip)  Motor. — After  section  of  the  nerve,  contraction-power 
of  the  stomach  is  lessened  but  not  altogether  lost.  The 
cerebral  vomiting  of  meningitis  and  of  other  brain  diseases 
is  due  to  irritation  of  the  vagus-nucleus,  and  paroxysmal 
vomiting  may  be  due  to  an  intermitting  pressure  on  the 
pneumogastric  nerve  in  the  neck. 

7.  Intestinal  branches  accelerate  the  action  of  the  intes- 
tines, but  intestinal  symptoms  from  diseases  of  the  nerve  or 
of  its  nucleus  are  exceedingly  rare. 

SPINAL  ACCESSORY  NERVE. 
The  "  accessory  "  portion,  arising  from  the  medulla,  joins 
the  pneumogastric  and  supplies  the  laryngeal  muscles. 
The  "  spinal "  portion,  arising  from  the  cervical  portion  of 
the  cord,  supplies  the  sterno-mastoid  and  the  portion  of  the 
trapezius  muscle  between  the  occipital  bone  and  the  acro- 
mion. The  nucleus  in  the  medulla  may  be  involved  in 
bulbar  paralysis ;  the  nerve-trunk  may  be  implicated  by 
meningitis,  tumors,  or  caries.  The  symptoms  of  nuclear 
disease  are  those  of  the  various  laryngeal  palsies.  Disease 
of  the  spinal  portion  is  followed  by  paralysis  of  the  sterno- 
mastoid  and  of  the  upper  portion  of  the  trapezius.  There  is 
an  absence  of  the  normal  prominence  of  the  sterno-mastoid 
muscle  in  the  neck,  and  the  head  is  rotated  with  difficulty 


DISEASES    OE   THE   SPINAL   ACCESSORY  NERVE.     763 

to  the  opposite  side.  The  head  may  be  held  obliquely,  but 
purely  paralytic  torticollis  does  not  occur.  The  paralysis  of 
the  upper  portion  of  the  trapezius  gives  a  concave  contour 
to  the  neck,  especially  marked  on  deep  inspiration;  the 
shoulder  falls  a  little,  the  scapula  recedes  from  the  spine, 
and  the  angle  is  rotated  inward  from  the  unopposed  action 
of  the  rhomboids  and  the  levator  anguli  scapulae.  Eleva- 
tion of  the  arm  is  also  impaired,  as  the  deltoid  loses  some 
of  the  support  from  M^hich  it  acts.  Bilateral  paralysis  may 
occur  with  progressive  muscular  atrophy,  and  is  not  uncom- 
mon in  children  in  consequence  of  chronic  meningitis  about 
the  foramen  magnum  damaging  both  spinal  accessory 
nerves.  If  both  sterno-mastoids  are  affected,  the  head  falls 
backward  ;  if  both  trapezii,  the  chin  sinks  upon  the  sternum. 

Spasm  of  the  Spinal  Accessory  Nerve  (Torticollis ; 
Wry-neck). —  i.  The  congenital  form  (fixed  wry-neck)  affects 
the  right  side  almost  exclusively.  The  sterno-mastoid  is 
shortened,  frequently  is  atrophied,  and  usually  is  hard  and 
firm.  In  some  of  the  cases  the  condition  is  thought  to 
depend  upon  injury  to  the  muscle  from  traction  upon  the 
neck  during  birth.  The  muscle  stands  out  prominently ; 
the  head  deviates  and  cannot  be  turned  toward  the  side  on 
which  the  muscle  is  contracted.  The  symptoms  are  rarely 
noticed  during  early  childhood,  because  of  the  shortness  of 
the  neck.  In  many  cases  there  is  an  associated  facial 
asymmetry,  which  by  some  is  thought  to  be  an  essential 
feature  of  the  congenital  form.  Congenital  torticollis  is  of 
slight  importance,  as  it  can  readily  be  cured  by  tenotomy. 

2.  Spasmodic  torticollis  may  be  either  clonic  or  tonic, 
the  two.  varieties  being  frequently  combined.  The  condition 
seems  to  be  more  frequent  in  males,  usually  between  thirty 
and  fifty  years  of  age ;  most  cases  occurring  in  females 
under  the  age  of  thirty  are  of  a  hysterical  nature.  There  is 
frequently  a  neurotic  family  history,  but  in  the  majority  of 
cases  no  exciting  cause  can  be  demonstrated. 

Symptoms. — Spasm  may  be  the  first  symptom,  but  in 
many  cases  there  is  a  preceding  pain  of  a  sharp  neuralgic 
or  a  dull  character,  or  a  sense  of  stiffness  may  antedate  the 
spasm.     The  spasm  usually  comes  on  gradually,  and  may 


764        MAXC.IL    OF  THE   PKACriCE    OF  MEDICIXE. 

involve  the  sterno-mastoid  alone,  or  there  may  be  an 
associated  spasm  of  the  upper  portion  of  tlie  trapezius  on 
the  same  side,  or  of  tlie  splcnius,  usualh'  upon  the  opposite 
side.  The  scaleni  and  platysma  myoides  occasionall}'  con- 
tract, or  more  rarely  the  deep  cervical  muscles.  Bilateral 
contraction  of  the  sterno-mastoid  muscles  causes  a  back- 
ward movement  of  the  head,  so  that  the  face  may  look  up- 
ward (retrocollic  spasm),  and  there  is  an  associated  spasm, 
of  the  frontales  muscles.  The  various  other  deformities 
may  be  inferred  by  a  knowledge  of  the  anatomy  of  the 
affected  muscles.  Clonic  spasms  may  recur  every  few 
minutes,  are  usually  associated  with  considerable  pain,  and 
in  time  the  muscles  become  hypertrophied.  The  clonic 
spasms  cease  during  sleep  and  are  aggravated  by  emotion, 
excitement,  or  fatigue.  In  some  cases  the  spasms  spread 
to  the  muscles  of  mastication,  of  the  face,  or  of  the  arms. 

Prognosis. — The  course  of  the  disease  varies.  After  a 
few  years  the  disease  ceases  to  progress  and  may  either 
remain  stationary  or  improve.  Recurrences  are  common. 
The  disease  is  usually  regarded  as  a  functional   neurosis. 

Treatm.ent. — The  spasm  may  be  relieved  by  valerianate 
of  zinc,  by  asafcetida,  or  by  sodium  bromide.  Chloral  and 
cannabis  indica  are  frequently  of  service.  Hypodermic 
injections  of  morphine  constitute  the  most  curative  mode  of 
treatment,  but  from  the  long  continuance  of  the  treatment 
the  habit  is  regularly  formed,  so  that  the  treatment  should 
not  be  inaugurated.  Galvanism  should  be  tried.  In  obsti- 
nate cases  nerve-stretching,  division,  and  excision  may  be 
performed. 

HYPOGLOSSAL  NERVE. 

Nuclear  disease  is  usually  degenerative  in  character, 
forms  part  of  bulbar  paralysis,  and  may  occur  with  loco- 
motor ataxia  or  from  acute  softening  from  obstruction  of 
the  blood-vessels.     The  symptoms  are  usually  bilateral. 

Supranuclear  disease  may  occur  anywhere  in  the  motor 
tract  between  the  nucleus  and  the  lowest  portion  of  the  as- 
cending frontal  convolution.  Paralysis  of  the  tongue  occurs 
upon  the  opposite  side,  and  is  usually  associated  with  hemi- 
plegia.    In  supranuclear  disease  the  tongue  does  not  waste. 


NEUKJT/S.  .  765 

In  infranuclcar  disease  the  fibres  of  the  nerve  may  be 
involved  by  tumor  or  meningitis,  or  the  nerve  may  be  com- 
pressed vi^ithin  its  foramen  by  caries  of  the  bones.  There 
may  be  a  neuritis  of  rheumatic  or  saturnine  origin.  In 
nuclear  and  infranuclear  disease  the  tongue  wastes  and  the 
reaction  of  degeneration  is  present. 

Symptoms. — In  unilateral  paralysis  the  tongue,  when 
protruded,  deviates  to  the  paralyzed  side;  in  bilateral  palsy 
it  lies  motionless  and  cannot  be  protruded.  Articulation 
and  mastication  are  interfered  with  in  proportion  to  the  ex- 
tent of  the  paralysis.  Sensation  and  taste  are  not  impaired. 
If  the  hypoglossal  fibres  be  involved  within  the  nucleus 
or  after  leaving  the  nucleus,  there  may  be  paralysis  of  the 
tongue  on  the  same  side,  with  opposite  hemiplegia  (Fig.  61). 

Spasm  of  the  tongue  may  be  part  of  a  general  spasm, 
such  as  epilepsy  or  chorea  ;  the  affection  occurs  in  some 
forms  of  stuttering.  The  tongue  is  a  not  infrequent  seat 
of  spasm  in  hysteria.  Spasm  of  the  tongue  may  also  be 
induced  by  reflex  irritation  of  the  fifth  nerve. 

A  rare  form  of  paroxysmal  clonic  spasm  is  described,  in 
which  the  tongue  is  protruded  as  many  as  forty  or  fifty 
times  a  minute.  Spasm  of  the  tongue  is  almost  regularly 
dependent  upon  functional  states  of  the  nervous  system  that 
are  removable  by  tonic  treatment.' 


6.   DISEASES  OF  THE  PERIPHERAL  NERVES. 

NEURITIS. 
Neuritis  may  be  localized  in  one  nerve  or  may  involve  a 
number  of  nerves.     For  convenience,  therefore,  a  localized 
and  a  general  or  multiple  form  are  described. 

Localized  Neuritis. 
Etiology. — Traumatism  is  the  most  frequent  cause  for  a 
localized  neuritis,  the  nerve  being  injured  by  wounds,  con- 
tusions, fractures  and  dislocations  of  bones,  sudden  violent 
muscular  exertion,  by  hypodermic  injections  of  irritants 
such  as  ether,  and  by  the  steady  strain  on  certain  muscles. 


766 


MA.Vr.lL    OF   THE    PRACTICE    OF  MEDICJXE. 


as  in  professional  palsies.  The  nerve  may  be  involved  by 
an  extension  of  inflammation  from  other  parts,  especially 
from  bone  disease.  A  nerve-trunk  max-  also  be  involved  by 
the  i^rovvth  of  tumors.  Cold  is  a  not  infrequent  cause  of 
neuritis,  the  facial  and  sciatic  nerves  being  most  commonly 
affected  from  this  cause.  This  form  is  often  spoken  of  as 
"  rheumatic  neuritis."  The  various  toxic  agents  to  be  con- 
sidered under  Multiple  Neuritis  may  act  upon  a  single  nerve. 

Pathology. — An  interstitial  and  a  parenchymatous  neur- 
itis occur. 

Interstitial  Neuritis. — The  inflammation  may  in\olve  the 
perineurium  or  may  extend  into  the  deeper  portions.  The 
connective  tissue  becomes  congested  and  infiltrated  by 
leucocx'tes.       The    nuclei    of  the    sheath   of  Schwann    are 


=^ 


Fig.  6g. — Normal   nerve-fibre  (Starr) :  a,  axis-cylinder  ;  b,  medullary  sheath  ;  c,  sheath  of 
Schwann  ;  d,  node  of  Ranvier  ;  i-,  incisure  of  Schmidt ;  f,  nucleus  of  sheath  of  Schwann. 


Fig.  70. — Degeneration  of  nerve-fibres  in  various  stages  (Starr). 


increased,  and  the  m\-elin  becomes  broken  up  into  frag- 
ments. The  axis-cylinder  may  ultimately  develop  degen- 
erative atrophy,  so  that  in  the  final  stages  the  nerve  is  rep- 
resented by  a  strand  of  very  fatty  connective  tissue  (the 
"  lipomatous  neuritis  "  of  Leyden).  Interstitial  neuritis  is  the 
form  which  usually  occurs  from  extension  of  inflammation 
from  carious  bone. 

Pareiicliyniatous  Neuritis. — Congestion  and  exudation  oc- 
cur in  the  nerv^e-trunk,  and  there  is  a  degeneration  of 
individual  nerve- fibres.  The  myelin-sheath  becomes  dis- 
integrated into  fatt}'  granules  ;  the  nuclei  of  the  sheath  of 
Schwann   multiph-.     In  severe  cases  the  axis-cylinder  also 


NEURITIS.  jGj 

undergoes  fatty  disintegration.  The  products  of  degeneration 
liquefy  and  are  absorbed,  leaving  only  the  collapsed  sheath 
of  Schwann.  In  this  form,  which  resembles  the  .secondary 
degeneration  occurring  in  a  nerve  divided  from  its  trophic 
centre,  the  interstitial  connective  tissue  is  but  slightly 
affected.  The  muscles  supplied  by  the  degenerated  nerve 
undergo  marked  atrophic  changes.  This  form  occurs  in 
traumatic  cases.  Regeneration  occurs  by  the  growth  of 
new  fibres  outward  into  the  affected  districts  of  the  nerve. 

The  two  forms  are  frequently  combined  in  non-traumatic 
cases. 

Symptoms. — There  is  weakness  or  paralysis  of  the 
muscles'  to  which  the  nerve-fibres  are  distributed  ;  motion 
is  painful,  and  there  may  be  at  the  onset  twitchings  or  con- 
tractions. Atrophy  of  the  muscles  ultimately  develops ; 
there  is  loss  of  the  faradic  irritability,  and  the  reaction  of 
degeneration  develops.  Pain,  of  a  boring  or  stabbing  cha- 
racter, is  felt  along  the  course  of  the  nerve  and  in  its  area 
of  distribution,  followed  by  numbness  or  anaesthesia.  Loss 
of  tactile  sensation  frequently  occurs  even  if  the  pain  be 
marked.  Tenderness  along  the  course  of  the  nerve-trunk 
usually  persists.  Trophic  changes  may  become  evident : 
the  skin  becomes  glossy  or  reddened  and  oedematous ;  the 
nails  become  defective ;  and  there  may  be  herpes,  increased 
surface  temperature,  localized  sweatings,  and  effusion  into 
the  joints.  A  localized  neuritis  may  in  rare  instances 
extend  upward  along  the  larger  nerve-trunks  (ascending  or 
migrative  neuritis),  and  may  even  reach  the  spinal  cord, 
causing  a  subacute  myelitis. 

Prog-nosis. — The  course  of  the  disease  is  usually  slow, 
but  recovery  should  occur  if  the  continuity  of  the  nerve- 
fibre  be  preserved.  Mild  cases  of  traumatic  neuritis  may 
pass  away  within  a  few  days. 

Treatment. — If  the  nerve  be  cut,  the  divided  ends  should 
be  sutured  on  well-known  surgical  principles.  The  injured 
part  should  be  placed  at  rest  in  a  padded  splint,  or  hot 
applications  may  first  be  applied  for  the  pain.  Electricity 
and  massage  are  of  service  to  the  paralyzed  muscles. 


768      maxr.ll  of  the  pkacivce  of  medicine. 

Multiple  Neuritis. 

Etiology. — The  causes  of  multiple  neuritis  may  be  thus 
tabulated:  (i)  The  toxiius  of  infectious  diseases,  as  diph- 
theria. t}-phoid  fever,  small-pox,  leprosy,  scarlet  fever, 
S)-philis,  tubercle,  grippe,  malaria,  and  beri-beri ;  (2)  cJievi- 
ical  poisons — ether,  alcohol,  coal-gas,  bisulphide  of  carbon, 
naphtha,  lead,  arsenic,  mercury,  phosphorus,  copper,  zinc, 
ergot,  and  morphine ;  (3)  anto-toxines  with  rheumatism, 
gout,  arthritis,  diabetes,  the  puerperal  state,  and  chorea; 
(4)  cachectic  conditions,  such  as  anaimic,  cancerous,  or  tuber- 
culous cachexia ;  (5)  idiopathic  (?)  cases  following  exposure 
to  cold  or  over-exertion. 

Pathology. — The  lesions  may  be  of  an  interstitial  neuritis 
alone,  of  a  parenchymatous  neuritis  alone,  or  the  two  forms 
may  be  combined.  The  peripheral  parts  of  the  nerves  are 
more  seriously  affected  than  are  the  central  parts.  The 
neuritis  may  involve  motor  nerves  alone  (as  in  lead- 
poisoning),  or  sensory  nerves  alone  (as  in  coal-gas  poison- 
ing) or  both  sensory  and  motor  nerves  may  be  affected 
(as  in  alcoholic  neuritis). 

Symptoms. — The  symptoms  are  those  of  neuritis,  pre- 
viously described,  differing  only  from  those  of  the  localized 
form  in  being  more  general  in  their  distribution.  As  the 
symptomatology  of  multiple  neuritis  is  so  varied,  it  will  be 
more  convenient  to  describe  separately  the  principal  clinical 
types. 

Acnte  Febrile  Polyneuritis. — The  onset  is  acute,  with  a 
chill,  fever  of  from  103°  to  104°  F.,  and  pains  in  the  back 
and  the  limbs.  Pain  and  tingling  occur  in  the  peripheral 
parts,  and  the  nerve-trunks  are  exquisitely  tender  on  pressure. 
Motor  weakness  becomes  evident  in  a  few  days,  the  exten- 
sors being  the  more  seriously  involved.  The  paralysis 
rapidly  extends  up  the  extremities,  and  may  even  involve 
the  trunk  or  the  face.  The  muscles  rapidly  waste,  faradic 
irritability  is  lost,  and  the  reaction  of  degeneration  appears. 
Trophic  changes  are  commonly  observed.  The  clinical 
picture  is  that  of  an  acute  ascending  palsy,  resembling  or, 
according  to  some,  being  identical  with  Landry's  paralysis. 


NKU/UTJS. 


769 


Death  occurs  in  from  one  to  three  weeks  in  the  severe 
cases.  In  milder  cases,  after  the  symptoms  have  persisted 
for  from  four  to  six  weeks  slow  improvement  begins,  but 
recovery  rarely  is  complete  under  one  or  two  years.  In 
some  cases  the  onset  is  more  gradual  and  the  course  of  the 
disease  more  prolonged,  so  that  the  clinical  type  resembles 
that  of  Duchenne's  paralysis. 

Alcoholic  neuritis,  the  most  common  form  of  the  disease, 
occurs  more  frequently  in  women  than  in  men.  The  onset 
may  be  acute,  accompanied  by  a  chill  and  by  fever  of  from 
101°  to  103°  F. ;  or  the  disease  may  begin  gradually,  with 
sensory  symptoms  in  the  feet  and  the  hands,  such  as  neural- 
gic pains,  tingling  and  pricking  feelings,  and  cramps  in  the 
muscles.  There  is  considerable  tenderness  along  the  course 
of  the  nerve-trunks.  Paralysis  next  occurs,  at  first  in  the 
feet,  then  in  the  hands  and  forearms,  and  the  characteristic 
wrist-drop  and  foot-drop  are  developed  (Fig.  71).  The 
affected  muscles  undergo  rapid  atrophy  and  show  the  reac- 
tion of  degeneration.  The  superficial  and  deep  reflexes  are 
lost.  Sensory  symptoms  may  consist  of  numbness  or  ting- 
ling, or  there  may  be  severe  neuralgic  pains.  There  may 
be  areas  of  anaesthesia  and  of  retarded  sensation.  The 
combination  of  anaesthesia  of  the  skin  with  extreme  hyper- 
aesthesia  and  soreness  of  the  muscles  is  highly  suggestive 
of  the  alcoholic  form  of  neuritis.  The  paralysis  may 
remain  localized  in  the  hands  and  feet,  and  after  a  stationary 


Fig.  71. — Multiple  alcoholic  neuritis  :  wrist-drop  and  foot-drop  (Gowers). 


period  of  several  months   slow  spontaneous   recovery  will 
ensue,  the  duration  of  the  disease  being  from  six  to  twelve 
months.     As  the  extensors  of  the  feet  usually  remain  para- 
49 


770        M.IXCAL    OF   rilE   PR  AC  TICK    OF  MEDIC  LYE. 

lyzed  for  some  time,  the  "  steppage  gait "  becomes  promi- 
nent and  is  characteristic  of  peripheral  neuritis.  In  other 
imd  more  mahgnant  cases  there  may  be  spreading  paralysis 
of  the- extremities,  trunk,  sphincters,  and  even  of  the  face, 
and  death  may  be  caused  by  involvement  of  the  muscles  of 
respiration. 

The  cerebral  s)'mptoms  of  alcoholic  neuritis  are  fre- 
quently well  marked.  There  may  be  convulsions  at  the 
onset  or  throughout  the  disease.  Delirium  with  extrava- 
gant hallucinations  is  usually  well  marked,  and  may  verge 
into  the  type  of  delirium  tremens.  Appreciation  of  time 
and  place  is  usually  lost.  In  some  cases  the  patient  passes 
into  the  t\phoid  condition,  with  low,  continued  fever  and 
muttering  delirium. 

Post-fcbrilc  Neuritis. — The  various  forms  of  post-febrile 
neuritis  ha\-e  been  described  under  the  respective  diseases 
that  precede  them.  Diphtheritic  paralysis,  the  most  com- 
mon and  serious  form,  may  involve  the  muscles  of  the 
palate,  eye,  or  heart,  or  may  be  generally  distributed  in  the 
extremities.  There  are  no  sensory  symptoms  in  the  major- 
ity of  cases  of  neuritis  following  other  infectious  diseases, 
and  the  distribution  of  the  paralysis  is  usually  paraplegic. 

Lead-paralysis  is  usually  preceded  by  anaemia,  colic,  con- 
stipation, and  the  blue-black  line  on  the  margin  of  the 
gums.  The  symptoms  of  lead-palsy  may  appear  abruptly 
or  gradually,  and  are  not  attended  by  sensory  disturbances. 
The  following  localized  lead-palsies  are  described : 

1.  Anti-brachial  type — paralysis  of  the  extensors  of  the 
fingers  and  the  wrists.  The  musculo-spiral  nerve  is  in- 
volved, causing  the  characteristic  wrist-drop. 

2.  Brachial  type,  involving  the  deltoid,  biceps,  brachialis 
anticus,  and  the  supinator  longus,  more  rarely  the  pectorals. 
This  form  is  bilateral,  and  may  follow  the  first  type  or  be 
primary. 

3.  Aran-Duchenne  type,  involving  the  small  muscles  of 
the  hands,  closely  resembling  the  earlier  stages  of  progres- 
sive muscular  atrophy. 

4.  Peroneal  type,  involving  the  lateral  peroneal  muscles 
and  the  extensors  of  the  toes,  producing  the  "  steppage  gait." 


NEURfTfS.  771 

5.  Laryngeal  type,  involving  the  adductors  of  the  larynx. 

In  other  cases  the  paralysis  becomes  more  generalized, 
gradually  involving  the  extremities.  There  are  occasionally 
seen  acute  cases  resembling  Landry's  paralysis.  There  has 
been  described  a  rare  form  of  lead-neuritis  in  which  atrophy 
and  paralysis  come  on  together  and  develop  proportionately. 

The  prognosis  of  lead-palsy  is  generally  good.  The 
course  of  mild  cases  is  about  four  months. 

Arsenical  paralysis  is  rare.  The  symptoms  are  chiefly 
motor,  resembling  those  of  alcoholic  neuritis.  The  "  step- 
page gait "  is  usually  well  marked.  Recovery  usually 
occurs  in  from  two  to  six   months. 

Coal-gas  neuritis  is  generally  slight,  and  involves  only 
sensory  nerves.  Numbness  persists  for  a  long  time  in  the 
hands  and  feet. 

Beri-beri,  or  Kak-ke. — This  disease,  which  occurs 
endemically  in  Northern  Brazil,  China,  Japan,  India,  the 
Straits  Settlements,  and  in  the  Malay  Archipelago,  is  a  mul- 
tiple neuritis  probably  due  to  infection  by  a  micrococcus. 
Foreigners  in  the  endemic  localities  are  usually  exempt. 
At  times  the  disease  assumes  epidemic  proportions  ;  in  1878, 
38  per  cent,  of  the  Japanese  army  were  affected.  Nothing 
is  accurately  known  as  to  the  etiology. 

Symptoms. — Two  principal  forms  are  described — an 
cedematous  or  "  wet  "  and  a  paralytic  or  "  dry  "  form.  The 
oedematous  form  begins  acutely,  with  fever,  oedema,  paresis, 
and  numbness  of  the  lower  extremities.  Effusion  into  serous 
cavities  may  occur.  The  liver  and  spleen  are  enlarged. 
The  dry  form  may  occur  primarily  or  may  be  a  develop- 
ment of  the  wet  variety.  Sensory  symptoms,  which  are 
prominent,  consist  of  anaesthesia  and  prickling  and  tingling 
sensations.  Paresis,  atrophy,  and  the  "  steppage  gait " 
develop.  A  malignant  form  of  the  dry  variety  occasionally 
occurs,  characterized  by  rapidly  ascending  paralysis  and  by 
suppression  of  urine. 

The  prognosis  of  the  mild  forms  is  good,  but  relapses  are 
common.  In  some  epidemics,  however,  the  mortality  is 
over  40  per  cent. 


'J-J2        MAXl'AL    OF  THE   PRACTICE    OF  MEDICINE. 

Treatment  of  Multiple  Neuritis. 
Rest  in  bed  is  essential,  and  salicylic  acid  or  the  salicy- 
lates are  recommended  during  the  earlier  stages  of  acute 
cases  with  fever.  Warm  applications  to  the  affected  limbs 
should  bo  made  by  packs  or  baths.  After  the  acute  stage 
has  passed,  gentle  rubbing  of  the  muscles  with  oil  and  mas- 
sage are  to  be  employed.  Warm  baths  of  98°  F.  are  to  be 
given  for  half  an  hour  several  times  a  day.  Contractures 
are  to  be  overcome  by  passive  movements  and  by  extension. 
The  interrupted  galvanic  current  should  be  employed  daily. 
Alcohol  should  be  cut  off  from  all  cases,  although  in  the 
alcoholic  form  the  reduction  should  be  gradual.  Of  drugs 
during  the  chronic  stage,  arsenic  and  strychnine  are  the 
most  valuable.  The  strength  should  be  supported  by  care- 
ful regulation  of  the  diet,  and  the  use  of  cod-liver  oil  is  gen- 
erally advisable. 

NEUROMATA. 

Tumors  situated  in  the  nerve-trunks  may  be  composed 
of  nerve-tissue  (the  true  neuromata)  or  of  other  tissues  (the 
false  neuromata). 

False  neuromata  are  chiefly  formed  of  fibrous  tissue.  More 
rarely  there  occurs  myxomatous  tissue,  sarcoma,  or  an  in- 
filtration of  the  nerve-fibres  by  carcinoma.  In  leprosy  the 
nerves  are  frequently  much  thickened  by  an  infiltrating 
growth  of  connective  tissue.  A  curious  variety  is  the  plexi- 
forni  neuroma^  which  consists  of  interlacing  cords  more  or 
less  nodular.  In  this  condition,  which  is  usually  of  con- 
genital origin,  hundreds  of  fibrous  nodules  may  occur  along 
the  course  of  the  nerve-trunks.  The  symptoms  of  false 
neuromata  are  seldom  evident,  although  in  some  cases  the 
symptoms  of  neuritis  may  appear. 

True  neuromata,  containing  nerve-fibres,  rarely  ganglionic 
cells,  may  form  small  subcutaneous  painful  tumors — 
tubercula  dolorosa.  These  tumors  are  not  always,  how- 
ever, pure  neuromata,  but  may  consist  of  fibrous  tissue 
or  may  be  adenomatous  growths  of  the  sweat-glands. 
True  neuromata  may  develop  on  the  cut   ends  of  nerves 


NKURALCfA.  773 

in    amputation-stumps,  in  which    situation    they  may  lead 
to  great  pain  and  distress. 

Treatment. — When  painful,  the  growths  may  be  excised. 

NEURALGIA. 

Etiology. — Under  the  term  "neuralgia"  are  included 
painful  affections  of  the  nerves  due  either  to  functional  dis- 
turbance or  to  neuritis.  The  causes  and  symptoms  of  neur- 
itis have  elsewhere  been  described. 

Members  of  neurotic  families  are  subject  to  neuralgic 
affections.  Women  are  more  often  affected  than  are  men, 
but  children  are  usually  exempt. 

General  debility,  anaemia,  excesses,  over-work,  and  ner- 
vous exhaustion  are  potent  predisposing  factors.  Neuralgia 
is  not  uncommon  with  malaria,  rheumatism,  gout,  syphilis, 
diabetes,  and  chronic  lead-poisoning.  Reflex  irritation  may 
act  as  an  exciting  cause ;  thus  obstinate  trifacial  neuralgia 
may  result  from  carious  teeth  or  from  eye-strain.  In  sus- 
ceptible patients  exposure  to  wet  and  cold  may  induce  an 
attack. 

Pathology. — Aside  from  the  cases  in  which  neuralgia  is 
dependent  upon  neuritis,  the  disease  is  a  pure  neurosis. 

Symptoms. — The  attack  may  be  preceded  by  chilliness, 
mental  depression,  or  tingling  in  the  part  to  be  affected. 
The  chief  symptom  is  pain,  of  a  paroxysmal,  stabbing,  burn- 
ing, or  darting  character,  localized  in  certain  groups  of 
nerves.  The  skin  of  the  affected  area  may  be  hyperaesthetic, 
and  spots  of  exquisite  tenderness  are  detected  at  certain 
points  along  the  nerve  where  it  makes  its  exit  through  a 
bony  canal  or  a  fibrous  sheath.  Vaso-motor  symptoms  may 
accompany  the  pain  ;  the  skin  may  be  cool,  or  hot  and 
burning,  and  there  may  be  areas  of  oedema  or  of  erythema 
or  herpes.  Twitching  of  the  muscles,  or  even  spasms,  mav 
occur  during  the  paroxysm.  The  attack  lasts  from  a  few 
minutes  to  a  number  of  hours  and  then  subsides.  The 
interval  between  the  paroxysms  varies  in  different  cases. 
Frequently  the  recurrences  are  at  regular  interv^als,  often 
only  at  the  menstrual  period. 

Clinical  Varieties. —  Trifacial  Neuralgia  (Tic  Douloureux). 


774        -VAXrAL    OF  THE  PRACTICE    OF  JJE£>/CEV£. 

— The  pain  is  felt  in  one  or  more  branches  of  the  nerve,  the 
ophthahiiic  division  being  most  frequently  affected.  Hyper- 
aesthesia  of  the  skin  and  of  the  mucous  membranes  is  com- 
mon, and  vaso-motor  phenomena  are  not  infrcqucnth'  pres- 
ent— flushing,  sweating,  salivation,  increased  nasal  discharge, 
and  lachrj-mation.  There  may  be  trophic  changes — ery- 
thema, induration  of  the  skin,  loss  of  hair  or  local  grayness. 
In  severe  cases  there  may  be  an  associated  spasm  of  the 
facial  muscles — the  "  tic  convulsif "  Tender  points  corre- 
spond to  the  supraorbital,  infraorbital,  and  mental  foramina, 
less  frequently  to  the  occipital  protuberance  and  the  upper 
cervical  spine.  Trifacial  neuralgia  is  frequently  of  reflex 
origin. 

Ccrvico-occipital Neuralgia. — The  pain,  which  is  usually  dull 
and  more  or  less  constant,  is  localized  over  the  back  of  the 
neck  and  the  head,  extending  forward  as  far  as  the  parietal 
eminences  and  the  ear.  There  is  frequenth'  hj-pereesthesia  of 
the  scalp.  The  most  important  tender  point  is  located  mid- 
way between  the  mastoid  process  and  the  spine,  where  the 
great  occipital  nerve  becomes  superficial.  Exposure  to  cold 
and  cervical  caries  are  the  most  frequent  causes  of  this 
form  of  neuralgia. 

Cervico-bracJiial  neuralgia,  which  involves  the  sensory 
nerves  of  the  brachial  plexus,  is  usually  most  intense  in  the 
axilla  or  along  the  course  of  the  ulnar  nerve.  When  the 
circumflex  nerve  is  involved  the  pain  is  in  the  deltoid.  The 
pain  may  be  so  increased  by  movement  as  to  render  the 
arm  helpless.  The  most  common  tender  points  are  the 
axillary,  the  circumflex  at  the  posterior  border  of  the  del- 
toid, the  superior  ulnar  behind  the  elbow,  and  the  inferior 
ulnar  in  front  of  the  wrist.  Cervico-brachial  neuralgia  more 
frequently  than  any  other  form  is  the  result  of  injury.  Some 
severe  forms  are  evidences  of  an  occupation-neurosis. 

Intercostal  neuralgia  is  very  common  in  hysterica:l  and 
anaemic  women.  Pain  is  felt  along  the  intercostal  nerves  in 
aneurysm,  caries,  and  pleurisy.  There  is  usually  a  dull, 
constant  pain,  with  acute  stabbing  exacerbations.  Painful 
points  are  detected  beside  the  vertebra,  under  the  angle  of 
the    scapula,  and    under  the    breast.      Pleurodynia  differs 


NEURA/.(i/A.  775 

from  true  intercostal  neuralgia  in  being  localized  in  one 
spot  not  corresponding  with  the  course  or  exit  of  the  inter- 
costal nerves.  The  pain  is  increased  by  expansion  of  the 
thorax  rather  than  by  lateral  movements  of  the  trunk. 
Herpes  zoster  occurs  with  the  most  aggravated  form  of 
intercostal  neuralgia,  which  may  persist  after  the  eruption 
has  subsided.  The  eruption  and  the  neuralgia  are  due  to 
neuritis. 

Ljuiibar  neuralgia  gives  rise  to  pain  along  the  crest  of  the 
ilium,  the  inguinal  canal,  and  the  spermatic  cord,  and  in  the 
testis,  scrotum,  and  labium  majus.  Irritable  testis  is  usually 
accompanied  by  syncopal  sensations. 

Coccygodynia,  which  is  common  in  women,  is  aggravated 
by  the  sitting  posture.  This  form  of  neuralgia  is  usually 
very  intractable. 

Sciatica. — The  pain  extends  down  the  back  of  the  thigh, 
often  reaching  as' far  as  the  foot.  The  pain  maybe  uni- 
formly distributed  along  the  course  of  the  nerve,  but  not 
infrequently  there  are  spots  in  which  it  is  more  intense. 
The  pain  is  usually  more  or  less  constant  and  of  a  gnawing, 
burning  character,  but  it  may  be  paroxysmal,  the  paroxysms 
being  usually  more  intense  in  damp  weather  and  at  night. 
The  pain  is  regularly  increased  by  walking;  the  knee  is 
bent  and  the  patient  walks  on  the  toes  to  diminish  the  ten- 
sion on  the  nerve.  The  painful  points  are  located  (i)  above 
the  hip-joint,  near  the  posterior  iliac  spine,  (2)  at  the  sciatic 
notch,  (3)  about  the  middle  of  the  thigh,  (4)  behind  the  knee, 
(5)  below  the  head  of  the  fibula,  (6)  behind  the  external 
malleolus,  and  (7)  oh  the  back  of  the  foot.  Tenderness  is 
usually  also  elicited  by  pressure  along  the  course  of  the 
nerve.  Muscular  wasting  and  fibrillary  twitchings  compli- 
cate the  severe  cases. 

Sciatica  is  most  common  in  those  with  a  gout}^  or  rheu- 
matic tendency.  The  nerve  may  be  compressed  by  intra- 
pelvic  growths  or  may  be  involved  by  spinal  caries. 

The  prognosis  must  be  made  with  caution,  as  many  cases 
of  neuralgia  prove  intractable  to  treatment. 

Treatment. — All  causes  for  reflex  irritation  must  be  dis- 
covered and  removed  if  possible.     A  tonic  and  supporting 


"/■jd        MAXCAL    OF  THE   PRACTICE    OF  MEDICEVE. 

treatment  is  of  the  greatest  importance.  The  patient  should 
be  built  up  in  every  possible  way.  Iron  and  arsenic  are 
required  for  anaemic  conditions ;  gouty  and  rheumatic  taints 
are  to  be  treated  ;  quinine  is  to  be  given  to  malarial  patients. 
The  diet  should  be  generous.  Fats  are  indicated  in  nearly 
all  of  the  cases,  and  a  liberal  amount  of  meat  is  to  be  allowed 
to  all  except  those  subject  to  gout.  Many  obstinate  cases 
are  benefited  by  residence  in  a  dry  inland  climate.  Strychnine, 
phosphorus,  and  cod-liver  oil  are  of  great  service. 

For  the  pain,  antipyrine,  phenacetine,  lactophenin,  chloral, 
croton-chloral,  the  bromides,  and  cannabis  indica  may  be 
given.  Aconite  and  gelsemium  are  recommended  for  tri- 
facial neuralgia.  Morphine,  codeia,  and  hypodermic  injec- 
tions of  cocaine  are  to  be  withheld,  because  of  the  danger 
of  forming  the  habit.  Local  applications  are  frequently  of 
service.  Heat,  stimulating  liniments,  freezing  of  the  skin 
by  ether  or  methyl-chloride  spray-s,  blisters,  or  application 
of  the  actual  cauter)^  may  be  employed.  Surgical  treatment 
may  be  required  for  obstinate  cases.  Nerve-stretching  is 
not  likely  to  be  followed  b}'  permanent  results.  Neurectomy, 
or  the  excision  of  a  portion  of  the  affected  nerve,  is  fre- 
quently followed  by  good  results,  but  the  pain  may  return 
in  time. 


7.  GENERAL  NERVOUS  DISEASES. 

INFANTILE   CONVULSIONS;   INFANTILE 
ECLAMPSIA. 

Etiology. — Convulsions  are  so  frequent  in  children  that  a 
special  mention  is  justifiable.  Owing  to  the  lack  of  develop- 
ment of  the  higher  cerebral  centres  of  children,  the  lower 
centres  are  but  improperly  controlled,  so  that  increased 
reaction  to  direct  or  reflex  stimulation  is  permitted.  The 
most  important  causes  for  convulsive  seizures  in  children 
are  the  following : 

I.  Rickets. — Convulsions,  usually  without  marked  febrile 
disturbance,  occur  from  slight  causes,  and  are  apt  to  be 
repeated  at  mtervals  for  months. 


INFANTILE    CONVULSIONS.  yj7 

2.  G astro-intestinal  Irritation. — This  most  common  cause 
arises  from  dietetic  errors,  indigestion,  or  worms.  The 
convulsions  are  usually  accompanied  by  fever. 

3.  General  exhaustion,  especially  if  due  to  diarrhoea! 
disease.  Convulsions  may  be  part  of  a  hydro-encephaloid 
condition. 

4.  MccJianical  congestion  of  the  brain ^  as  with  violent 
attacks  of  coughing. 

5.  Deficient  aeration  of  blood,  as  with  croup,  diphtheria, 
or  vitiated  air  in  incubators. 

6.  During  the  first  few  days  of  life,  from  severe  brain- 
injury  during  birtJi.  If  the  convulsions  be  severe  and  per- 
sistent, meningeal  hemorrhage  should  be  suspected. 

7.  Peripheral  irritation,  as  teething,  phimosis,  or  otitis. 

8.  Acute  febiile  conditions,  especially  at  the  onset  of 
measles,  scarlet  fever,  and  pneumonia. 

9.  Convulsions  may  usher  in  or  accompany  any  serious 
disease  of  the  nervous  system  in  children. 

10.  Convulsions  in  infancy  are  not  infrequently  epileptic. 
The  symptoms  may  be  preceded  by  signs   of  irritation 

of  the  nervous  system — restlessness,  irritability,  and  twitch- 
ings.  The  attack  begins  with  a  fixation  of  the  eyeballs ; 
the  face  becomes  pale,  the  limbs  and  trunk  become  rigid 
and  stiff.  The  fingers  and  toes  are  inverted  (carpopedal 
spasm).  Respiratory  movement  is  impaired,  so  that  the 
face  becomes  cyanotic.  The  spasm  may  relax,  or  may 
become  clonic  as  in  epilepsy.  In  some  cases  clonic  spasms 
are  marked  from  the  start,  and  usually  begin  in  the  hands 
and  face. 

The  spasm  may  be  followed  by  muscular  rigidity  for 
some  little  time.  In  convulsions  due  to  indigestion  the 
attack  may  be  single ;  in  other  cases  attacks  follow  each 
other  with  great  rapidity.  Attacks  coming  irregularly  and 
without  assignable  cause  in  children  over  two  years  of  age 
are  likely  to  prove  to  be  true  epilepsy.  Convulsions  may 
be  followed  by  slight  paresis  or  may  lead  to  meningeal 
hemorrhage  with  hemiplegia. 

The  prognosis   is  usually  good.     A   dubious  prognosis 


77  S        M.IXCAL    OF  rilE   PRACTICE    OF  MEDIC  I XE. 

should  be  given,  however,  in  the  case  of  weakly  subjects,  as 
fatal  exhaustion  may  be  induced. 

Treatment. — The  first  and  most  important  measure  is  to 
search  for  the  cause  of  the  seizure,  and  to  remove  it  if 
possible.  If  indigestion  be  the  cause,  a  prompt  emetic 
should  at  once  be  given,  or  the  stomach  may  be  washed 
out.  For  the  attack  itself,  if  severe,  whiffs  of  chloroform 
should  be  given,  and  an  enema  containing  chloral  (gr.  ij) 
and  sodium  bromide  (gr.  v-x)  should  be  administered,  these 
doses  being  suitable  for  a  child  of  from  six  to  twelve 
months.  No  time  should  be  lost  in  immersing  the  child  in 
a  bath  at  95°  F. ;  baths  of  a  higher  temperature  are  not 
suitable.  After  the  bath  an  ice-cap  should  be  employed  or 
cold  applications  should  be  made  to  the  head.  Morphine 
may  be  necessary  in  case  of  recurring  convulsions,  but  the 
drug  should  be  administered  with  extreme  caution,  and 
should  never  be  ordered  for  infants  under  six  months  of 
age.  For  a  child  of  one  year,  gr.  y^^-  to  y^-  hypodermically 
will  be  a  sufficient  dose. 

EPILEPSY. 

Etiology. — Among  the  remote  causes  which  induce  this 
disease,  heredity  is  the  most  important,  a  neurotic  family 
history  being  obtained  in  about  one-quarter  of  all  cases. 
A  direct  inheritance  of  epilepsy  is  rare,  but  the  parents  are 
apt  to  suffer  from  nervous  diseases  or  to  be  the  victims 
of  the  alcohol  habit.  Any  vicious  influence  deteriorating 
the  parent  stock  predisposes  to  the  development  of  epi- 
lepsy in  the  offspring.  Consanguineous  marriages  exert 
a  distinct  influence  upon  the  causation  of  the  disease. 
Epilepsy  may  interchange  with  insanity  in  different  gen- 
erations. 

An  immediate  exciting  cause  is  determined  in  but  one- 
third  of  all  cases.  There  may  be  blows  on  the  head,  dissi- 
pation, fright,  or  continued  reflex  irritation.  Many  cases  in 
children  date  from  teething  or  from  acute  infectious  diseases. 
Although  in  many  cases  the  exciting  cause  may  be  removed, 
the  nerve-centres  may  have  formed  the  habit  of  discharging 
nerve-force,  so  that  the  seizures  continue  through  life. 


EPILEPSY.  779 

Males  are  more  frequently  affected  than  females.  The 
disease  appears  before  the  thirteenth  year  in  one-third  of 
the  cases,  between  the  thirteenth  and  nineteenth  years  in 
one-third,  and  between  the  nineteenth  and  thirtieth  years  in 
one-third  of  the  cases.  After  the  thirtieth  year  idiopathic 
epilepsy  is  rare.  "  An  epilepsy  which  develops  after  the 
thirty-fifth  year  of  age  is  not  idiopathic,  but  is  due  to  some 
organic  brain  disease,  to  the  abuse  of  alcohol,  to  reflex  irrita- 
tion, or  other  causes,  which  in  some  cases  may  be  so  hidden 
as  to  be  exceedingly  difficult  of  recognition  "  (H.  C.  Wood). 
In  the  great  majority  of  cases,  recurring  epileptic  seizures 
in  those  over  the  age  of  thirty  are  due  to  brain  syphilis. 

The  pathology  of  epilepsy  is  obscure.  A  degeneration 
of  the  neuroglia  in  the  brain  has  been  described  by  some 
observers.  The  generally  accepted  theory  is  that  the  seiz- 
ures are  due  to  a  discharging  lesion  of  the  brain-cortex,  so 
that  an  overflow  of  nerve-force  occurs. 

Symptoms. — Loss  of  consciousness  with  general  convul- 
sions is  known  as  grand  nial ;  loss  of  consciousness  with- 
out convulsions,  as  petit  vial.  Localized  convulsions, 
usually  without  loss  of  consciousness,  are  described  as 
Jacksonian  or  cortical  epilepsy. 

Grand  Mal. — The  attack  may  be  preceded  by  peculiar 
sensations,  described  as  aurcB,  which  give  warning  to  the 
patient  that  an  attack  is  impending.  Sensory  aurae  are  the 
most  common ;  they  differ  in  character  in  different  patients, 
but  are  constant  in  the  one  subject.  An  aura  consists  of  a 
peculiar  sensation,  felt  in  some  part  of  the  body,  mounting 
upward  to  the  head.  Aurae  of  special  senses  are  occasion- 
ally observed.  An  ocular  aura  consists  of  visual  sensa- 
tions— flashes  of  light  or  of  color,  bizarre  forms,  double 
vision,  or  even  blindness.  In  auditory  aurae  abnormal 
sounds  or  voices  may  be  heard.  An  olfactory  aura,  which 
takes  the  form  of  a  bad  smell,  is  rather  infrequent.  Psy- 
chical aurae  are  not  uncommon ;  the  patient  may  feel 
alarmed  or  may  be  in  terror,  or  there  may  be  a  vague  sense 
of  strangeness  or  a  dreamy  sensation.  In  some  cases  the 
attack  is  preceded  by  forced  movements  ;  the  patient  may 
run  forward  with  great  speed  ("  procursive  epilepsy "),  or 


780         MAXr.-lL    OF   THE   PRACTICE    OF  MEDICIXE. 

may  turn  rapidly  around  as  if  on  a  pivot.     In  many  cases 
the  aura  is  absent. 

The  fit  is  usually  abrupt;  the  patient  falls  to  the  ground 
unconscious.  Preceding  the  attack  there  is  generally  a 
wild,  harsh  scream  or  groan.  The  fit  occurs  in  three 
stages : 

1.  Totiic  Spasm. — The  head,  eyes^  and  mouth  are  rotated 
to  the  side  on  which  the  spasm  is  more  intense ;  the  body 
is  stiff  and  rigid.  The  hands  are  clenched,  the  arms  and 
forearms  flexed,  the  legs  extended,  and  the  feet  extended 
and  inverted.  The  body,  however,  is  not  always  distorted 
in  the  same  manner,  as  the  muscular  spasms  may  not  be 
equally  intense.  The  face,  at  first  pale,  becomes  dusky  or 
livid,  owing  to  the  respiratory  spasm.  The  tonic  stage  lasts 
for  from  a  few  seconds  to  one  or  two  minutes. 

2.  Clonic  Stage. — Tremulous  vibrations  occur  in  the  mus- 
cles ;  the  vibrations  increase  in  range  until  the  limbs  are 
jerked  and  tossed  violently  about.  The  face  is  frightfully 
contorted,  foamy  saliva  is  forced  from  the  mouth,  and  the 
tongue  is  apt  to  be  severely  bitten.  Respirations  are  noisy 
and  stertorous.  Urine  and  feces  may  be  passed  involun- 
tarily, especially  in  nocturnal  attacks.  The  pupils  are  im- 
movably dilated,  and  after  the  attack  usually  show  remark- 
able oscillations.  The  temperature  is  usually  normal,  but 
in  case  the  attack  be  prolonged  a  slight  rise,  rarely  to  102° 
F.,  may  be  observed.  The  clonic  stage  lasts  for  three  or 
four  minutes,  and  the  patient  passes  into  the — 

3.  Stage  of  Coma. — The  patient  becomes  quiet  and  passes 
into  a  deep  sleep,  awakening  after  a  few  minutes  or  hours 
with  headache,  mental  confusion,  and  muscular  soreness. 
After  the  attack  the  reflexes  are  usually  increased.  The 
urine  is  usually  increased  in  quantity  after  the  attack,  and 
may  contain  albumin.  In  rare  instances  the  patient  passes 
from  one  spasm  into  another  without  regaining  conscious- 
ness. In  this  status  cpileptiais  the  temperature  may  rise  to 
107°  F.,  and  the  patient  is  apt  to  die  from  exhaustion. 

Post-epileptic  Syi)iptonis. — The  patient  may  emerge  from 
the  coma  in  a  peculiar  trance-like  condition,  and  may  per- 
form purposeless  and  incongruous  actions,  at  times  so  appar- 


EPir.KPSY.  781 

ently  rational  that  it  may  be  impossible  to  believe  that  the 
patient  is  not  conscious.  At  times  this  condition  o{  epileptic 
autoviatisni  passes  into  the  condition  of  epileptic  mania,  in 
which  condition  the  patient  is  dangerous  or  even  homicidal. 
After  the  attack  slight  transient  hemiplegia  or  aphasia 
may  be  noticed.  Epilepsy  is  frequently  succeeded  by 
mental  degradation  which  may  ultimately  lead  to  complete 
dementia. 

Nocturnal  epilepsy  may  occur  without  the  patient's  know- 
ledge, so  that  the  condition  may  exist  for  years  before  the 
diagnosis  is  suspected. 

2.  Petit  Mal. — The  ordinary  type  consists  of  sudden 
loss  of  consciousness.  The  patient  suddenly  stops  what  he 
is  doing,  the  face  becomes  pale  and  fixed,  the  pupils  dilate; 
but  after  a  i^^sr  seconds  consciousness  is  regained  and  the 
patient  resumes  his  work  or  conversation  as  if  nothing  had 
happened.  Aurae  are  infrequent  in  petit  mal.  In  some 
instances  the  attack  consists  of  forced  movements,  such  as 
the  sudden  running  forward  of  procursive  epilep.sy.  In 
other  cases,  during  the  attack  the  patient  may  perform 
some  automatic  action,  such  as  undressing  himself  or  tear- 
ing to  pieces  whatever  may  be  within  reach.  There  may 
be  sudden  outbursts  of  maniacal  excitement  during  which 
crimes  and  assaults  may  be  committed :  these  cases  of 
"  masked  epilepsy "  are  of  great  medico-legal  interest. 
Somnambulistic  epilepsy  consists  in  the  performance  of 
accustomed  acts  while  in  a  somnambulistic  state. 

Attacks  of  petit  mal  terminate  in  some  instances  in  facial 
twitchings  or  in  hysteroid  convulsive  movements.  The 
various  manifestations  of  petit  mal  are  exceedingly  varied. 
In  the  majority  of  cases  attacks  of  grand  mal  ultimately 
develop,  and  the  two  forms  may  alternate. 

3.  Jacksonian  epilepsy,  which  is  regularly  due  to  irrita- 
tive lesions  of  the  motor  centres,  especially  of  the  motor 
cortical  zone,  differs  from  true  epilepsy  in  the  fact  that  con- 
sciousness is  retained. 

The  spasm  occurs  in  limited  groups  of  muscles,  which 
are  always  the  same  in  each  patient.  Preceding  the  attack 
there  may  be   numbness   or  tingling  of  the   affected  part. 


78: 


M.IXCAL    OF  THE  PRACTICE    OF  MEDICLXE. 


In  growing  lesions  the  march  of  the  spasm  ma\-  be  observed, 
and  accurate  localization  becomes  possible. 

Diagnosis.^ Petit  mal  ma)-  be  mistaken  for  syncope, 
vertigo;  or  indigestion,  but  in  these  conditions  conscious- 
ness is  not  lost.  Jackson ian  epilepsy  is  rarely  mistaken 
for  other  conditions.  Localized  spasms  ma}-,  however, 
occur    in  uraemia  and  in  progressive  paresis. 

Grand  mal  is  to  be  diagnosed  from  uraemia,  simple 
convulsions  in  children,  convulsions  from  organic  brain 
disease,  malingering,  and  hystero-epilepsy.  Uraemia  is  diag- 
nosed by  the  high  arterial  tension,  the  scanty  and  albumin- 
ous urine,  and  the  presence  of  fever  during  the  attack. 

Simple  convulsions  in  children  are  usually  due  to  some 
recognized  cause  and  are  not  apt  to  be  repeated.  Convul- 
sions due  to  organic  brain  disease,  such  as  tumors  of  the 
cerebellum  and  progressive  paresis,  are  to  be  diagnosed  by 
attention  to  the  history  and  the  other  symptoms.  Malin- 
gerers may  closely  simulate  epilepsy,  but  the  tongue  is  not 
bitten,  foaming  at  the  mouth  does  not  occur,  and  strong 
pressure  by  the  thumbs  over  the  supraorbital  notches  will 
rapidly  cut  short  the  attack.  The  diagnosis  from'  hystero- 
epilepsy  is  to  be  made  by  the  following  points,  thus  tabu- 
lated by  Gowers  : 


Epileptic. 


Hysteroid. 


Apparent  cause   . 
Warning      .    .    .    , 

Onset        

Scream 

Convulsion      .    .    . 

Biting       

Micturition  .  .  , 

Defecation  .  .  , 

Talking    .    .  .  .  , 

Duration      .  .  .  , 

Restraint  necessary 
Termination     .    .    . 


None. 

Any,  but  especially  unilat- 
eral or  epigastric  aurce. 

Always  sudden. 

At  onset. 

Rigidity  followed  by  "jerk- 
ing," rarely  rigidity  alone, 

Tongue. 

Frequent. 

Occasional. 

Never. 

A  few  minutes. 

To  prevent  accident. 
Spontaneous. 


Emotion. 

Palpitation,  malaise,  chok- 
ing, bilateral  foot -aura. 

Often  gradual. 

During  course. 

Rigidity  or  "  struggling," 
throwing  about  of  limbs 
or  head,  arching  of  back. 

Lips,  hands,  or  other  people 
or  things. 

Never. 

Never. 

Frequent. 

More  than  ten  minutes,  often 
much  longer. 

To  control  violence. 

Spontaneous  or  induced 
(water,  etc.). 


The  prog-nosis  for  cure,  except  in  Jacksonian  epilepsy,  is 


KPii.F.rsY.  783 

bad,  but  the  disease  may  be  materially  relieved  by  treatment. 
The  pro^mosis  is  betterin  cases  coming  on  in  adults,  due 
to  syphilis,  and  in  children  in  cases  where  the  convulsions 
have  followed  teething  or  acute  fevers.  L^jjilepsy  does  not 
tend  materially  to  shorten  life. 

The  question  of  the  intellectual  future  of  the  patient  is 
always  a  serious  one.  Mental  degradation  occurs  in  a  con- 
siderable proportion  of  cases,  but  epilepsy  is  not  necessarily 
incompatible  with  an  active  and  useful  life. 

Treatment. — In  cases  of  reflex  or  of  Jacksonian  epilepsy 
the  cause  of  the  irritation  should  be  removed.  In  some 
cases  the  results  are  brilliant,  but  in  many  instances  there  is 
but  partial  improvement,  the  habit  of  nerve-discharge  of 
the  higher  centres  having  been  established.  In  cases  of 
epilepsy  in  which  the  aura  is  slow,  attempts  should  be  made 
to  check  the  spasm  by  the  inhalation  of  amyl  nitrite ;  or  in 
case  of  ascending  sensory  aura  of  an  extremity,  the  patient 
should  be  taught  to  encircle  the  part  firmly  with  the  hand 
or  with  a  tight  bandage.  Unfortunately,  the  aurae  are 
usually  of  too  short  duration  to  allow  of  any  preventive 
treatment. 

During  the  attack  the  patient  should  be  placed  in  a 
horizontal  position,  the  clothing  loosened,  and  a  gag  firmly 
placed  between  the  teeth,  to  prevent  the  tongue  from  being 
bitten.  Inhalations  of  chloroform  or  of  ether  are  per- 
missible in  protracted  or  severe  paroxysms,  or  a  hypodermic 
injection  of  morphine  may  be  administered. 

Dietetic  and  Hygienic  Treatment. — The  patient  should  do 
all  things  in  moderation,  never  in  excess.  Marriage  should 
be  interdicted.  Habits  of  firm  but  kindly  discipline  are  im- 
portant for  growing  epileptic  children.  The  diet  should  be 
chiefly,  but  not  altogether,  vegetable ;  meat,  however,  may  be 
allowed  once  a  day.  The  patient  should  be  restrained  from 
going  to  bed  until  gastric  digestion  has  been  completed. 

Medicinal  Treatment. — Bromides  are  the  most  serviceable 
drugs  in  the  treatment  of  epilepsy.  Of  the  various  bromides, 
the  salt  of  sodium  is  the  most  preferable.  The  bromide 
treatment  should  be  pushed  until  mild  affects  of  bromism — 
acne,  mental  depression,  foul  breath,  and  muscular  weakness 


7S4        M.IXLAL    OF  THE   PR.ICT/CE    OF  MFD/C/XE. 

— ha\e  been  produced,  and  should  then  be  reduced  so  that 
the  patient  is  kept  just  within  the  physiological  action  of 
the  drug,  so  that  the  palate- reflex  is  lost.  As  a  rule,  from 
14  toi^  drams  daily  are  sufficient  for  an  adult.  The  drug 
should  be  largely  diluted  in  water  or  in  milk,  and  the  liabil- 
ity to  acne  is  said  to  be  diminished  b\'  the  joint  administra- 
tion of  arsenic.  The  bromide  treatment  should  be  continued 
for  at  least  two  or  three  years  after  the  cessation  of  the 
attacks. 

The  combination  of  antipyrine  with  the  bromides  is  fre- 
quently of  service.  Wood  claims  that  a  mixture  of  bromide 
of  ammonium  (gr.  xx-xxx),  antipyrine  (gr.  vij),  and  Fowler's 
solution  (TTL  ij~iij)  affords  the  best  combination  known  for 
the  majority  of  cases,  the  indicated  doses  being  admin- 
istered twice  daily.  Sulphonal  may  also  be  given  advan- 
tageously with  the  bromide  treatment. 

Among  other  forms  of  treatment  employed  for  their 
alleged  specific  action  are  valerian,  belladonna,  oxide  of 
zinc,  and  nitrate  of  silver  and  borax,  but  these  drugs  prove 
almost  worthless  when  tried. 

PARALYSIS    AGITANS. 

Etiology  and  Synonyms. — Paralysis  agitans  usually  ap- 
pears between  the  fiftieth  and  sixtieth  years,  and  is  rare  be- 
fore the  age  of  forty.  Men  are  more  commonly  attacked  than 
women,  in  the  proportion  of  5  :  3.  Hereditary  influences  can 
be  traced  in  1 5  per  cent,  of  all  cases.  In  about  one-third  of  all 
cases  an  exciting  cause  can  be  ascertained — emotion,  fright, 
exposure  to  cold,  physical  fatigue,  or  acute  disease.  In  other 
cases  the  disease  begins  without  known  cause.  It  is  not 
a  disease  of  vice.  Synonyms:  Shaking  palsy ;  Parkinson's 
disease. 

Pathology. — No  lesions  are  found  to  account  for  the  con- 
dition, but  it  is  supposed  that  the  symptoms  are  due  to  pre- 
mature senile  changes  in  the  cerebral  cortex. 

Symptoms. — The  characteristic  symptoms  are  tremor  and 
muscular  rigidity. 

The  tremor  develops  insidiously,  and  usually  appears  first 
in  the   hands  or  the   fingers.     At  first  the  tremor  may  be 


PARALYSIS  AG /TANS. 


785 


controlled  by  the  will,  but  later  it  becomes  more  continuous 
and  cannot  be  controlled.  The  tremors  are  short,  rapid, 
(being  about  5  to  the  second),  and  in  the  fingers  may  be 
rhythmical,  so  that  the  motion  resembles  that  produced  by 
rolling  some  small  body  between  the  thumb  and  the  fingers. 
The  handwriting  shows  the  character  of  the  fine  tremors. 
It  is  peculiar  for  the  tremor  to  continue  when  the  hand  or 
the  limb  is  at  rest  and  to  cease  during  voluntary  motions, 
so  that  the  patient  may  safely  carry  a  glass  of  water  to  the 
lips.  In  other  cases  the  tremor  cannot  be  thus  checked, 
and  in  rare  instances  it  may  even  be  increased  by  voluntary 
motions.  Emotions  regularly  increase  the  tremor.  The 
tremor  extends  to  various  parts  of  the  body  without  fixed 
order  of  progression,  but  the  face  is  rarely  involved.  Vol- 
untary motions  are  performed  slowly  and  with  but  little 
power. 

Muscular  rigidity,  which  is  characteristic  of  the  advanced 
stages  of  the  disease,  gives  rise  to  changes  in  the  attitude, 
the  gait,  and  the  facial  expression.  The  attitude  is  charac- 
teristic (Fig.  72) ;  the  body  is  inclined  forward,  and  the  ex- 
tremities are  in  a  general 
condition  of  flexion.  The 
inclination  of  the  body 
forward  may  throw  the 
patient  in  front  of  the  cen- 
tre of  gravity,  so  that  he 
will  have  to  walk  faster 
and  faster,  or  even  to 
run,  to  avoid  falling  for- 
ward— the  so-called  "  fes- 
tinating  gait."  The  face 
is  fixed,  expressionless, 
and  immobile ;  the  eye- 
brows are  raised,  giving 
a  characteristic  facies  to 
which  the  name  "  Park- 
inson's mask  "  has  been 
applied.     The  voice  is  a  high-pitched  monotone. 

Sensory  symptoms  consist  of  soreness    and  a  sense  of 

50 


Fig.  72. — Paralysis  agitans  (St.  Leger). 


786        J/./.\r.//,    OF   TJJE   rKACTICE    OF  MEDICINE. 

fotigue  in  the  afifected  muscles.  Various  vaso-motor  symp- 
toms may  occur.  The  surface-temperature  over  the  afifected 
muscles  may  be  increased.  Mental  derangement  does  not 
occu,r,  although  the  patients  may  become  emotional.  The 
urine  may  contain  an  excess  of  phosphates,  or  there  may 
be   pol\-uria. 

Diagnosis. — Disseminated  sclerosis  develops  earlier  in 
life,  n\'stagmus  is  {)resent,  the  speech  is  scanning,  and  there 
is  no  characteristic  attitude.  The  diagnosis  from  post- 
hemiplegic tremor  is  readily  made  by  the  history  of  the 
case,  the  increased  reflexes,  and  the  hemiplegic  distribution 
of  the  latter  disease.  Senile  tremor  is  rare  under  the  age 
of  seventy,  and  is  usually  marked  in  the  muscles  of  the 
neck,  producing  slight  movements  of  the  head.  Toxic 
tremors  from  alcohol  or  from  tobacco  usually  occur  only 
on  motion,  and  the  tremor  is  more  pronounced,  showing 
considerable  range. 

Prognosis. — The  condition  is  incurable,  but  it  does  not 
tend  to  shorten  life. 

Treatment. — A  number  of  drugs  have  been  recom- 
mended, but  no  form  of  treatment  seems  to  have  any  per- 
manent influence  upon  the  disease.  Mental  and  physical 
rest  should  be  enjoined,  and  prolonged  lukewarm  baths 
may  be  advised.  Hyoscine  h)-drobromate  (gr.  y^-jj  gradually 
increased)  has  been  given  with  temporary  benefit.  Dana 
has  used  the  bromide  of  uranium  (gr.  -g^)  with  apparently 
good  results.     Arsenic  may  also  be  used. 

ACUTE    DELIRIUM. 

Etiology  and  Synonyms. — Acute  delirium  usually  occurs 
during  active  adult  life,  and  may  be  due  to  alcoholism,  to 
profound  grief,  or  to  over-work ;  or  the  condition  may 
appear  as  a  sequel  to  sunstroke,  fevers,  or  injuries  to  the 
head.     Synonyms  :  Bell's  mania ;  Acute  periencephalitis. 

Pathology. — The  nature  of  the  disease  is  unknown.  By 
some  authors  the  lesion  consists  of  hyperaimia  and  oedema 
of  the  brain  and  its  membranes,  with  a  choking  of  the 
lymph-channels  of  the  pia  and  of  the  cortex  by  leucocytes. 


CHOREA  787 

According  to  others,  the  symptoms  are  due  to  nerve- 
poisoning  by  unknown  toxic  products. 

tSymptoms. — The  onset  may  be  preceded  by  the  prodro- 
mal symptoms  of  irritabihty,  restlessness,  and  insomnia. 
The  developed  disease  presents  two  stages,  one  of  maniacal 
delirium,  the  other  of  apathy,  collapse,  and  coma.  The 
delirium  comes .  on  rapidly  and  reaches  a  grade  of  wild 
frenzy  with  hallucinations  and  delusions.  There  is  absolute 
insomnia.  The  temperature  ranges  between  102°  and  105° 
F.,  but  falls  to  subnormal  in  the  advanced  stages.  The 
stage  of  mania  lasts  for  from  a  few  hours  to  several  days 
and  is  succeeded  by  a  stage  of  quiet  in  which  the  patient 
lies  semi-comatose,  responding  incoherently  when  aroused. 
In  the  advanced  stage  the  pulse  fails  and  the  symptoms  of 
collapse  become  evident.  There  may  be  irregular  desqua- 
mation of  the  skin,  ulceration,  gangrene,  pemphigus,  or  areas 
of  complete  anaesthesia. 

The  diagnosis  should  be  made  from  the  following  con- 
ditions :  (i)  Masked  pneumonia  with  maniacal  delirium  at  the 
onset;  (2)  acute  urzemia  with  mania  followed  by  coma; 
(3)  typhoid  fever  with  marked  cerebral  symptoms  at  the 
onset;  (4)  delirium  tremens;  (5)  acute  meningitis. 

Prognosis. — The  duration  of  the  disease  is  about  a  week, 
but  it  may  be  protracted  for  two  or  three  weeks.  The 
disease  is  almost  uniformly  fatal.  When  recovery  occurs 
the  mind  is  almost  regularly  affected. 

Treatment. — During  the  maniacal  stage  the  patient  should 
be  actively  purged,  and  in  robust  cases  free  venesection 
should  be  resorted  to.  The  patient  is  to  be  quieted  by 
morphine,  hyoscine,  or  chloral,  and  when  tractable  the  cold 
bath  or  cold  pack  may  be  employed  for  its  calmative  effect. 
Good  results  are  claimed  for  the  hypodermic  use  of  ergotine 
in  large  doses,  15  grains  being  given  every  eight  hours. 

CHOREA, 

Etiology  and  Synonyms. — The  disease  is  more  common 
in  females  than  in  males,  and  three-fourths  of  all  cases 
occur  between  the  ages  of  five  and  fifteen.     Chorea  is  rare 


ySS       JJ.IXLAL    OF  TJIE   PRACTiCE    OF  MEDICIXE. 

before  the  fourth  year.  Negroes  arc  usuall}'  exempt.  The 
disease  is  most  eommon  in  high-strung,  nervous,  excitable 
children,  especially  these  who  are  ambitious  at  school. 
The  exciting  cause  in  15  per  cent,  of  all  cases  is  fright, 
but  mental  worry,  grief,  or  sudden  trouble  may  also  pre- 
cipitate an  attack.  Ocular  defects  and  reflex  irritation  do 
not  seem  to  produce  true  chorea.  An  antecedent  history  of 
rheumatism  is  obtained  in  about  one-fifth  of  the  cases.  In 
only  2  per  cent,  of  the  cases  does  chorea  antedate  the  rheu- 
matic complaint.  Chorea  may  occur  after  certain  infectious 
diseases — scarlet  fever,  whooping-cough,  gonorrhoea,  sec- 
ondary syphilis,  and  septic  infections — and  may  also  com- 
plicate pregnancy,  especially  in  primipara;  during  the  first 
five  months.  Syiionyins :  St.  Vitus's  dance  ;  Sydenham's 
chorea. 

Pathology. — There  are  no  characteristic  lesions  in  chorea. 
In  some  cases  vascular  changes  are  found  in  the  nervous 
system — hyaline  transformation,  exudation  of  leucocytes, 
small  punctate  hemorrhages,  and  thrombosis  of  the  smaller 
arteries — but  these  changes  are  inconstant.  Endocarditis  is 
the  most  frequent  lesion  found  at  autopsies,  occurring  in 
about  90  per  cent,  of  the  cases.  The  endocarditis  may  be 
of  the  malignant  variety. 

The  nature  of  the  disease-pjveess  in  chorea  is  not  yet 
accurately  known ;  three  theories  for  its  causation  are 
advanced:  (i)  That  chorea  is  a  functional  brain  disorder, 
leading  to  an  instability  of  the  nerve-cells  controlling  the 
motor  apparatus,  induced  by  hyperasmia  or  anaemia,  by 
psychical  influences,  or  by  central  or  reflex  irritation.  (2) 
That  chorea  is  due  to  embolism  of  the  smaller  cere- 
bral arteries.  This  view  is  favored  by  the  experimental 
production  of  chorea  in  animals  by  injecting  fine  insolu- 
ble particles  into  the  carotids.  All  cases  of  chorea,  how- 
ever, cannot  be  thus  explained,  as  histological  examination 
of  the  brain  may  be  negative.  (3)  That  chorea  owes  its 
origin  to  a  microbic  infection  at  present  unknown.  This 
view  seems  highly  probable,  although  it  does  not  explain 
why  chorea  is  so  frequently  excited  by  fright  or  other 
psychical  disturbance. 


CHOREA.  789 

Symptoms. — The  disease  may  begin  abruptly  or  may 
be  preceded  by  prodromata.  The  child  becomes  restless, 
is   fidgety,  irritable,  and  emotional. 

Three  grades  of  the  developed  disease  are  described  by 
Osier : 

1.  Mild  cJiorca,  in  which  the  muscular  affection  is  slight, 
speech  is  not  seriously  affected,  and  the  general  health 
remains  good.  In  the  mild  cases  there  are  constant  irregu- 
lar, jerky  motions  involving  usually  a  hand  or  a  hand  and 
the  face.  There  may  only  be  awkwardness  or  slight  inco- 
ordination of  voluntary  motions. 

2.  The  severe  form,  in  which  the  choreic  movements  be- 
come general,  and  are  so  pronounced  that  the  patient  cannot 
get  about,  feed,  or  undress  himself.  The  speech  is  usually 
affected,  and  there  may  be  motor  weakness  on  one  side  of 
in  the  limb  most  affected. 

3.  The  maniacal  form,  ox  chorea  ijisam'e/is,  characterized 
by  profound  cerebral  disturbances  and  by  violent  choreic 
motions.  There  is  active  delirium,  and  there  may  be  hyper- 
pyrexia, especially  in  the  fatal  cases. 

■  The  individual  symptoms  may  be  thus  described  : 
I.  Motor  symptoms  may  not  pass  beyond  awkwardness  or 
slight  inco-ordination,  or  they  may  develop  into  unwilled 
clonic  spasms  of  various  parts.  The  hands  are  usually 
first  involved,  then  the  face  and  subsequently  the  legs.  The 
movements  may  be  confined  to  one  side — hemichorea.  The 
attack  usually  begins  on  the  right  side,  but  in  rarer  instances 
the  movements  may  be  general  from  the  start.  The  muscles 
of  the  trunk  and  of  the  thighs  are  usually  bilaterally  affected. 
In  about  one-fourth  of  the  cases  the  speech  becomes 
affected,  from  involvement  of  the  lips  and  tongue.  In  mild 
cases  there  is  merely  embarrassment  or  hesitancy ;  in 
severer  cases  articulation  becomes  jumbled  and  incoherent, 
so  that  the  child  ceases  from  attempts  to  talk.  The  in- 
spiratory muscles  may  be  affected,  so  that  the  patient  will 
emit  sighing  or  odd  barking  sounds.  Choreic  movements 
generally  cease  during  sleep.  There  is  no  evidence  that 
the  muscles  of  the  gastro-intestinal  tract,  the  bladder,  the 
rectum,  or  the  bronchi  are  ever  affected,  and  irregular  con- 


793      .y.ixr.iL  of  the  practice  of  medicixe. 

tractions  of  the  papillai')'  hcart-nuiscles  probabl)'  do  not 
exist. 

Muscular  ivcakncss  is  not  uncommon,  and  rarely  amounts 
to  more  than  an  enfeeblement  of.  the  grip  or  a  dragging  of 
the  foot.  In  other  cases  there  may  be  more  evident  paresis, 
either  of  the  hemiplegic,  paraplegic,  or  monoplegic  type 
("  paralytic  chorea  "). 

2.  SiNSory  Disturdauccs. — Pain  in  the  muscles  of  the 
affected  limbs  is  uncommon,  but  pain  and  tenderness 
along  the  nerve-trunks  may  be  marked,  especially  in  cases 
of  hemichorea.  Numbness  and  tingling  or  pricking  sen- 
sations are  occasionally  encountered.  Multiple  neuritis  may 
occur.     Headache  is  frequent  and  may  be  persistent. 

Mental  syniptoiiis  are  rarely  absent,  although  rarely  are 
they  pronounced.  There  may  be  irritability  of  temper  with 
emotional  outbreaks,  and  a  change  in  the  moral  character 
of  the  child.  Memory  and  aptitude  for  study  are  impaired. 
Melancholia  is  not  uncommon.  In  rare  instances  dementia 
develops.  Aggravated  cases  of  chorea,  the  chorea  insanicns, 
are  characterized  by  delusions,  hallucinations,  delirium,  and 
even  mania. 

The  reflexes  in  chorea  may  be  normal ;  in  one-half  the 
cases  the  knee-jerk  is  diminished  or  lost.  Cutaneous  affec- 
tions are  common  in  chorea,  but  are  generalh'  due  to  the 
arsenic  treatment  or  to  allied  rheumatic  affections.  The 
skin  affections  embrace  erythematous  and  papular  pigmen- 
tations, rashes,  herpes  zoster,  erythema  nodosum,  and  pur- 
pura rheumatica.  Fever  occurs  in  about  one-eighth  of  all 
cases,  and  is  usually  slight.  Any  febrile  condition  other 
than  a  slight  transient  rise  of  temperature  is  indicative  of 
some  complication — rheumatic  arthritis,  pericarditis,  or  en- 
docarditis. Fatal  cases  of  chorea  insaniens  are  usually 
accompanied  by  a  high  ante-mortem  temperature. 

Heart  Symptoms. — Neurotic  palpitation  is  not  uncommon. 
Cardiac  murmurs  occur  in  from  25  to  30  per  cent,  of  all 
cases,  and  may  be  either  of  haemic  or  of  organic  origin. 
H?Emic  murmurs  are  most  commonly  observed  between  the 
third  and  fourth  weeks.     Acute  choreic  endocarditis  rarely 


CHOREA.  791 

gives  rise  to  symptoms.  The  following  statements  are 
given  by  Osier : 

"  In  thin,  nervous  children  a  systolic  murmur  of  soft 
quality  is  extremely  common  at  the  base,  particularly  at 
the  second  left  costal  cartilage,  and  is  probably  of  no 
moment. 

"  A  systolic  murmur  of  maximum  intensity  at  the  apex, 
and  heard  also  along  the  left  sternal  margin,  is  not  uncom- 
mon in  anjEmic,  enfeebled  states,  and  does  not  necessarily 
indicate  either  endocarditis  or  insufficiency. 

"  A  murmur  of  maximum  intensity  at  apex,  with  rough 
quality,  and  transmitted  to  axilla  or  angle  of  scapula,  indi- 
cates an  organic  lesion  of  the  mitral  valve,  and  is  usually 
associated  with  signs  of  enlargement  of  the  heart. 

"  When  in  doubt  it  is  much  safer  to  trust  to  the  evidence 
of  eye  and  hand  than  to  that  of  the  ear.  If  the  apex-beat 
is  in  the  normal  position,  and  the  area  of  dulness  is  not 
increased  vertically  or  to  the  right  of  the  sternum,  there  is 
probably  no  serious  valvular  disease. 

"  The  endocarditis  of  chorea  is  almost  invariably  of  the 
simple  or  warty  form,  and  in  itself  is  not  dangerous ;  but  it 
is  apt  to  lead  to  those  sclerotic  changes  in  the  valve  which 
produce  incompetency.  Of  1 10  choreic  patients  examined 
more  than  two  years  after  the  attack,  54  presented  signs  of 
organic  heart  disease. 

"  Pericarditis  is  an  occasional  complication  of  chorea, 
usually  in  cases  with  well-marked  rheumatism." 

The  diagnosis  is  usually  evident.  Chorea  should  not 
be  mistaken  for  spastic  diplegia  in  children,  for  cerebral 
atrophy,  or  for  Friedreich's  ataxia.  In  the  former  case  the 
onset  in  infancy,  the  steady  and  chronic  course,  increased 
reflexes  and  muscular  rigidity,  and  the  impaired  intellect 
are  distinguishing  features.  In  Friedreich's  ataxia  the 
scanning  speech,  spinal  curvature,  nystagmus,  deformities 
of  the  feet,  and  the  slow,  inco-ordinate  movements  render 
the  diagnosis  easy.  Hysteria  may  closely  resemble  chorea, 
but  the  movements  are  rhythmic  and  not  choreiform  in 
character,  and  other  hysterical  symptoms  are  present. 

Prognosis. — Recovery  is  the  rule,  although  there  exists 


79-      M.ixr.iL  OF  THE  pkactice  of  medicixe. 

in  chorea  a  tendency  to  recurrences,  especialh'  in  rheumatic 
cases.  Recurrences  are  most  frequent  during  the  spring 
months.  The  total  mortality  is  about  2  per  cent.  The 
mildest  cases  get  well  in  two  or  three  weeks.  The  ordinary 
duration  is  about  two  months,  but  cases  may  drag  along 
for  from  three  to  six  months.  The  ultimate  prognosis,  how- 
ever, is  that  of  the  associated  cardiac  lesions. 

Treatment. — Excessi\'e  brain-work  and  eye-strain  at 
school,  and  the  competing  for  prizes,  shoukl  be  prohibited 
in  nervous  children,  especially  in  those  who  have  had  pre- 
vious attacks  of  chorea.  The  general  nutrition  of  the 
child  should  be  maintained,  and  anaemic  conditions  should 
promptly  be  met  by  the  administration  of  iron  and  arsenic. 
For  the  attack  itself  rest  and  seclusion  constitute  important 
elements  in  the  treatment,  and  are  insisted  upon  by  Osier. 
The  child  should  be  put  to  bed  and  kept  quiet  until  the 
movements  have  ceased.  By  this  procedure  the  liability  to 
heart  complication  is  materially  diminished.  The  child 
should  be  kept  quiet,  and  should  not  be  excited  by  toys  or 
by  seeing  too  many  people.  The  diet  should  be  nourishing 
and  abundant.  Arsenic  is  the  best  form  of  medicinal  treat- 
ment, and  is  given  as  a  matter  of  routine  practice.  Chil- 
dren bear  the  drug  well.  Fowler's  solution  is  to  be  given 
in  3-minim  doses  well  diluted,  after  meals;  the  dose  should 
be  increased  by  2  minims  every  second  or  third  day  until 
from  12  to  15  minims  are  taken  at  each  dose.  Should  toxic 
symptoms  appear — vomiting,  diarrhoea,  itching  of  the  eye- 
lids, oedema,  or  skin  affections — the  drug  should  be  stopped 
for  three  or  four  days  and  then  be  resumed  at  the  same 
dose  as  that  last  taken.  According  to  Osier,  arsenic  seems 
to  exert  no  specific  action  upon  the  disease,  but  does  good 
by  improving  the  general  condition. 

Of  other  remedies,  cimicifuga,  chloral,  sulphonal,  physo- 
stigmine,  antipyrine  in  20-  to  60-grain  doses  throughout 
the  day,  and  quinine  in  large  doses  have  been  recommended. 
The  zinc  compounds,  stiychnine,  and  sodium  bromide  may 
also  be  tried  in  obstinate  cases.  Iron  is  required  in  nearly 
all  cases  to  combat  anaemic  conditions. 

For   chorea   insaniens   h}'drotherapy,  in  the  form  of  the 


CJIOKEA.  793 

wet  pack  or  the  bath,  should  be  tried,  and  the  patient 
should  be  quieted  by  chloral,  morphine,  or,  in  the  severest 
cases,  by  whiffs  of  chloroform.  The  cardiac  affections  are  to 
be  treated  on  general  principles.  Obstinate  cases  may  be 
benefited  by  change  of  air  and  by  enforced  rest  and  seclusion. 

Choreiform  Affections. 

Habit-spasm  (Habit-chorea  ;  Simple  Tic). — This  condition 
is  common  in  childhood,  and  may  persist  during  life.  The 
patients  are  frequently  over-grown  children  of  a  neurotic 
personal  or  family  history.  There  may  be  twitching  of  the 
eyelids,  facial  grimaces,  shrugging  of  the  shoulders,  or  short 
inspiratory  sniffs.  In  severer  forms  nearly  all  the  muscles 
of  the  face  are  affected.  A  "  generalized  tic  "  occurs  in 
children  and  in  adults  and  may  persist  for  years.  The 
muscles  of  the  extremities  and  of  the  trunk  suddenly  jerk, 
producing  the  effects  of  a  general  electric  contraction 
("  electric  chorea"). 

Tic  Convulsif  (Gilles  de  la  Tourette's  Disease). — In  this 
form  which  usually  occurs  in  nervous  children  with  a  neur- 
otic family  history,  in  addition  to  motor  spasms  there 
occur  explosive  utterances  of  sounds  or  of  words.  A 
sound  may  be  repeated  over  and  over  again  {echolalia),  or 
obscene  and  profane  words  may  be  used  {coprolalia).  In 
some  cases  fixed  ideas  are  present ;  of  these,  afithniomania 
is  the  most  common,  in  which  condition  the  patient  feels 
obliged  to  count  a  certain  number  of  figures  before  almost 
every  action. 

Huntingdon'' s  Chorea  (Chronic  Chorea). — This  rare  disease 
is  characterized  by  its  hereditary  nature,  a  tendency  to 
insanity  and  suicide,  and  its  late  onset  between  the  thirtieth 
and  fortieth  years.  When  one  or  both  parents  have  been 
subject  to  the  disease,  one  or  more  of  the  offspring  invari- 
ably become  affected ;  but  the  hereditary  character  of  the 
disease  is  peculiar  in  that  it  never  skips  one  generation  to 
manifest  itself  in  another.  The  pathology  of  the  disease  is 
obscure. 

The  symptoms  are  first  manifested  in  the  hands  by  irreg- 
ular movements  ;  later  the  movements  are  disorderly  and 


794        .V.I.Vr.lL    OF   THE   PRACTICE    OF  MED/CIXE. 

inco-ordinatc,  and  have  not  the  jcrk\-  character  of  the  true 
choreic  contractions.  Slow  involuntary  facial  ijrimaces 
occur ;  the  gait  becomes  swaying  and  irregular,  and  has 
been. aptly  compared  to  that  of  a  drunken  man.  The  arms 
and  hands  are  usually  in  more  or  less  constant  irregular 
motion.  The  speech  is  affected  in  the  majority  of  cases, 
becoming  slow,  hesitating,  and  indistinct.  Mental  impair- 
ment becomes  progressively  marked,  and  ultimately  termi- 
nates in  dementia. 

TETANY;    TETANILLA. 

Etiology. —  This  condition,  \\liich  is  rare  in  the  United 
States,  most  conimonh^  occurs  before  the  twentieth  year. 
In  the  great  majority  of  cases  an  exciting  cause  can  be  dis- 
covered— exposure  to  cold,  acute  diseases,  especially  typhoid 
fever,  fatigue,  lactation  ("nurse's  contracture"),  or  preg- 
nancy. In  young  children  the  indications  of  rickets  are 
seldom  absent.  Tetan}'  occurs  in  about  one-sixth  of  the 
cases  of  removal  of  the  thyroid  gland,  and  may  be  fatal. 
Epidemics  of  tetany  are  described  as  occurring  on  the 
Continent  of  Europe,  and  appear  to  be  due  to  some  un- 
known infection.  A  rare  but  fatal  form  complicates  dilata- 
tion of  the  stomach. 

The  pathology  of  the  disease  is  unknown.  It  is  prob- 
able that  the  disease  depends  upon  the  action  of  some  toxic 
agent  upon  the  motor  centres. 

Symptoms. — The  spasms  are  bilateral,  and  begin  in  the 
hands  and  feet.  The  fingers  are  flexed  at  the  metacarpo- 
phalangeal joints,  extended  at  the  others  ;  the  thumb  is 
flexed  and  adducted;  the  palm  is  hollowed.  The  vvri.st  is 
flexed,  and  the  arm  may  be  folded  over  the  chest.  The  feet 
are  extended  and  inverted  ;  the  toes  are  flexed.  In  severe 
cases  the  muscles  of  the  trunk  and  of  the  face  may  be 
involved, -and  there  may  be  trismus.  Dyspnoea  and  cyano- 
sis may  result  from  spasm  of  the  respiratory  muscles.  The 
spasms  are  usually  paroxysmal,  lasting  from  several  minutes 
to  several  hours  or  even  da)-s,  but  in  some  severe  forms  the 
symptoms  are  continuous  for  several  weeks.  In  the  acute 
forms  there  may  be  a  moderate  fever,  a  feeling  of  "  pins- 


MIGKAfNE.  795 

and-needles "  in  the  hands,  and  a  cramp-like  pain  in  the 
affected  muscles.  During  the  height  of  the  paroxysm,  and 
persisting  for  several  weeks  afterward,  there  is  a  greatly 
increased  excitability  of  the  affected  nerves  to  the  galvanic 
and  the  faradic  current,  tetanic  contractions  following  the 
application  of  a  current  which  in  health  would  produce  no 
appreciable  reaction.  The  slightest  tap  on  the  affected 
muscle  causes  also  a  conspicuous  contraction.  The  cha- 
racteristic spasm  may  also  be  induced  by  pressure  oh  the 
artery,  sometimes  by  pressure  on  the  nerves  of  the  limb 
("  Trousseau's  phenomenon  "). 

Diagnosis. — From  tetanus  the  disease  is  distinguished  by 
the  fact  that  the  earliest  symptom  in  tetanus — trismus — is 
the  latest  in  tetany.  Hysterical  contractures  are  almost 
invariably  unilateral,  while  tetany  never  is.  Cases  of  carpo- 
pedal  spasms  in  rickety  children  should  not  be  regarded  as 
cases  of  true  tetany. 

The  prognosis  is  favorable  except  in  those  cases  following 
thyroidectomy  or  dilatation  of  the  stomach.  Future  attacks 
are  liable  to  occur,  however,  if  the  exciting  cause  be  repeated. 

Treatment. — The  cause  of  the  disease  should  be  traced 
and  removed.  Lactation  should  be  stopped,  and  in  all  cases 
a  tonic  form  of  treatment,  with  baths  and  cold  sponging, 
should  be  advised.  Sodium  bromide  relieves  the  spasm 
most  effectively,  but  cannabis  indica  or  chloral  may  also  be 
used.  Ice  to  the  spine  has  been  recommended.  Electrical 
treatment  is  disappointing.  Faradism  is  contraindicated. 
Massage  under  chloroform-narcosis  has  been  followed  by 
good  results  in  obstinate  cases. 

MIGRAINE. 

Etiology  and  Synonyms. — This  affection,  which  is  often 
inherited,  is  more  common  in  women  and  in  members  of 
neurotic  families.  In  many  of  the  cases  there  is  a  history 
of  rheumatic  or  gouty  taint.  The  existing  cause  may  be 
mental  or  bodily  fatigue,  emotions,  indigestion,  or  the  eating 
of  some  particular  article  of  food.  Among  reflex  causes 
should  be  mentioned  uterine  disease,  eye-strain,  abnormal 
conditions  of  the  nose  or  of  the  naso-pharynx,  and  carious 


796        MAXL'.IL    OF   THE    PRACTICE    OJ    MEDICIXE. 

teeth.  A  reflex  source  of  irritation  should  always  be 
suspected  in  the  migraine  of  young  patients.  The  attacks 
often  appear  with  striking  periodicity,  and  usually  cease 
after  the  climacteric,  or  in  men  after  the  fiftieth  }'ear. 
Synonyms:   Hemicrania;  Sick  headache. 

Pathology. — The  nature  of  the  disease  is  unknown. 
Liveing's  theory  is  that  it  is  a  nerve-discharge  from  sensory 
centres — the  sensory  equivalent  of  epilepsy ;  according  to 
others  the  disease  is  a  vaso-motor  neurosis. 

Symptoms. — Premonitory  symptoms  are  present  in 
many  cases.  There  may  be  malaise,  lassitude,  and  a 
sense  of  chilliness.  Visual  prodromes  are  not  uncom- 
mon— hemianopia,  spots  of  dimness  of  vision  or  scoto- 
mata,  apparitions,  balls  or  flashes  of  light,  and  zigzag 
lines.  Sensory  prodromes  consist  in  numbness  or  tingling 
of  a  hand  or  an  arm,  or  of  peculiar  sensations  in  any  part 
of  the  body.  There  may  be  a  condition  of  intense  emo- 
tional activity.  Motor  prodromes  consist  in  temporary 
weakness  of  certain  groups  of  muscles  or  of  aphasia. 

The  prodromal  symptoms  are  not  always  present.  In 
some  cases  they  may  comprise  the  entire  attack,  not  being 
followed  by  headache. 

The  characteristic  symptom  of  migraine  is  the  violent 
paroxysmal  headache. 

Beginning  over  one  side,  usually  most  intense  over  the 
frontal  region  or  over  the  eye,  the  pain  grows  more  and 
more  unendurable.  In  rarer  instances  the  headache  is 
bilateral. 

The  pain  is  usually  described  as  of  a  sharp,  boring  cha- 
racter, and  is  regularly  increased  by  the  slightest  sound  or 
light.  Prostration,  though  temporary,  is  extreme.  During 
the  early  part  of  the  attack  the  face  may  be  pale  and 
pinched,  and  there  may  be  a  marked  difference  between  its 
two  sides.  Subsequently  the  face  becomes  flushed  from 
vaso-motor  dilatation.  During  the  attack  there  is  usually 
mental  confusion,  or  even  temporary  loss  of  memory.  The 
pulse  may  be  slow  and  the  temporal  artery  contracted  and  in 
a  condition  of  arterio-sclerosis.  When  the  headache  reaches 
its    climax    nausea    and   \omiting    commonly   appear;    the 


OCCUPA  TION-NE UR OSES.  797 

vomiting  generally  affords  relief,  so  that  the  patient  may- 
fall  at  orce  into  a  sound  sleep  and  awal<e  refreshed. 

The  dv  ration  of  an  attack  varies  from  several  hours  to 
several  days. 

Migraine  is  not  accompanied  by  fever  except  in  chil- 
dren, in  whom  a  temperature  of  102°  to  103°  F,  may  be 
developed. 

Prognosis. — Much  can  be  done  to  render  the  attacks  less 
frequent  and  severe,  but  the  disease  cannot  be  radically  cured 
by  medication.  Spontaneous  cure  usually  occurs  between 
the  fortieth  and  fiftieth  years. 

Treatment. — Each  patient  is  usually  aware  of  the  causes 
that  precipitate  an  attack,  and  if  these  causes  be  avoided 
the  paroxysms  are  rendered  much  more  infrequent.  Periph- 
eral irritations,  such  as  eye-strain,  nasal  hypertrophies,  or  ade- 
noid growths  in  the  naso-pharynx,  require  appropriate  treat- 
ment. Attacks  of  migraine  become  infrequent  during  good 
health  ;  the  patient  therefore  should  be  built  up,  and  gouty 
and  rheumatic  tendencies  should  be  corrected.  During  the 
paroxysm  the  patient  should  be  put  to  bed  and  kept  abso- 
lutely quiet.  A  small  cup  of  strong  hot  coffee  frequently 
affords  relief  Much  benefit  is  derived  from  the  use  of 
antipyrine  or  phenacetine,  especially  when  given  in  small 
repeated  doses.  If  there  be  conspicuous  pallor,  nitroglycerin 
in  does  of  gr.  y^  may  be  given  every  two  hours.  Can- 
nabis indica  (gr.  \,  Herring's  English  Extract),  sodium 
bromide  (gr.  xxx),  and  chloral  hydrate  (gr.  x-xv)  are  all 
of  service.  A  prolonged  course  of  cannabis  indica  is  fre- 
quently beneficial  in  reducing  the  number  of  attacks. 
Of  other  remedies,  caffeine,  guarana,  ergot,  and  sodium 
salicylate  have  been  recommended. 

OCCUPATION-NEUROSES. 

Etiology. — Certain  localized  motor  affections  occur  in 
those  whose  occupation  requires  the  constant  repetition  of 
complicated  muscular  movements.  The  most  common 
form  is  "  writer's  cramp,"  but  piano-  and  violin-players, 
telegraphers,  and  cigarette-rollers  may  be  similarly  affected. 
Men  are  more  frequently  attacked  than  women,     Predispo- 


^^-.Q 


gb      MAxr.iL  OF  THE  practice  oe  medicine. 

sition  is  afiforded  by  an}-  of  the  causes  leading  to  neuras- 
thenia. 

Patholog-y. — Tlie  condition  is  one  of  local  neurasthenia, 
the  affected  nerve-centres  being  in  a  condition  of  "  irritable 
weakness." 

Symptoms. — The  principal  sj'mjitoms  are  pain  and 
spasm.  A  paraK-tic  form  has  also  been  described.  The 
symptoms  of  "  writer's  cramp  "  may  be  taken  as  a  type. 
There  is  a  feeling  of  fatigue  in  the  affected  muscles,  amount- 
ing to  actual  pain  when  writing  is  attempted ;  tremor  and 
irregular  spasmodic  contractions  occur,  rendering  the  writ- 
ing illegible ;  later  the  pain  may  be  more  continuous,  may 
spread  over  the  arm,  and  may  be  accompanied  b}'  tender- 
ness along  the  course  of  the  nerve-trunks. 

The  prog-nosis  must  be  made  guardedly,  as  the  condition 
tends  to  become  chronic,  and  even  when  relieved  by  treat- 
ment the  affection  is  liable  to  recur. 

Treatment. — It  is  important  that  in  writing  the  motions 
should  be  made  from  the  arm  or  the  forearm,  and  not  from 
the  wrist  or  the  little  finger,  as  the  fixed  point.  When  the 
symptoms  are  first  noticed  rest  is  imperative.  The  various 
devices  of  complicated  pen-holders  only  serve  to  stave  off 
the  disability  and  allow  the  patient  to  do  his  work  while  the 
malady  is  really  getting  worse.  Massage  and  systematic 
gymnastics  are  of  service.  Electricity  does  not  seem  to  do 
good.  No  form  of  treatment,  however,  is  of  benefit  that  is 
not  combined  with  rest.  The  general  nutrition  of  the 
patient  should  be  improved  in  every  way.  Nervine  tonics, 
as  phosphorus  and  strychnine,  are  to  be  recommended. 

NEURASTHENIA. 

Etiology. —  Nervous  weakness  and  irritability  occur 
when  the  expenditure  of  energy  exceeds  its  supply.  The 
following  classification  of  causes  is  given  by  Starr  : 

A.  Excessive  expenditure  of  nerve-energy  (primary  neuras- 
thenia):  (i)  Bad  hereditary  influences,  weak  nervous  sys- 
tem ;.  (2)  feebleness  in  childhood,  with  poor  nervous  system  ; 
(3)  wrong  methods  of  training ;  (4)  the  struggle  for  exist- 


NEURAS'J'JIENIA.  799 

ence;  (5)  anxiety,  mental  depression,  worry,  fear;  (6)  men- 
tal or  physical  over-work  ;  (7)  sexual  excesses. 

B.  Deficient  siipply  of  nervous  energy  (secondary  neuras- 
thenia):  (i)  Weakening  diseases  of  all  kinds,  of  an  organic 
nature ;  (2)  indigestion  and  dyspepsia,  with  auto-infection 
by  toxic  products;  (3)  gout,  rheumatism,  uric-acid  diathe- 
sis; (4)  infectious  diseases — typhoid,  grippe,  malaria;  (5) 
alcoholism  and  the  abuse  of  drugs. 

Pathology. — There  are  no  anatomical  lesions.  The  con- 
dition consists  of  "  irritable  weakness  "  of  the  nervous  centres. 

The  symptoms  of  neurasthenia  are  so  varied  that  only  a 
brief  description  can  be  given  of  the  important  manifesta- 
tions of  the  disease.  The  various  symptoms  are  grouped 
in  patients  in  an  infinite  variety  of  combinations. 

Cerebral  and  Mental  Symptoms. — There  is  an  inability  to 
perform  the  ordinary  mental  work.  The  patient  is  moody, 
apprehensive,  irritable,  and  depressed,  and  complains  of  a 
sense  of  fulness  in  the  head,  of  throbbing,  or  even  of  actual 
headache.  Suboccipital  headache  is  common,  and  is  usually 
associated  with  insomnia.  The  eyes  are  easily  tired  after 
reading  for  a  few  minutes. 

Spinal  Symptoms. — There  are  weariness  on  exertion,  pain 
in  the  back,  and  tender  spots  along  the  spine.  Pain  over 
the  cervical  vertebrae  and  the  sacrum  is  not  uncommon. 
Sexual  neurasthenia  is  characterized  by  nocturnal  emis- 
sions, impaired  power,  and  a  distressing  dread  of  impo- 
tence. 

Vaso-motor  symptoms  consist  of  hot  and  cold  flashes, 
localized  sweatings,  transient  blueness,  or  oedema.  Palpita- 
tion, irregular  heart-action,  and  painful  feelings  in  the  heart 
are  commonly  present,  and  distress  the  patient  with  the 
belief  that  he  has  serious  organic  disease  of  the  heart. 
Tachycardia  may  occur. 

G astro-intestinal  Symptoms. — There  may  be  nervous  dys- 
pepsia, or  hyperacidity,  or  hypersecretion.  Constipation  is 
the  rule.  There  may  be  membranous  colitis,  especially 
in  women.  Tympanites  is  a  common  symptom.  Gastro- 
intestinal neurasthenia  is  often  associated  with  dilatation  of 


8oO        MAXr.lL    OF   THE   PRACTICE    OF  MEDICLXE. 

the  -Stomach  and  floating  kidnc)',  the  combined  conditions 
being  termed  "  enteroptosis." 

Urinary  Symptoms. — In  man\-  cases  oxalate  of  hme  or 
uric  acid  is  present  in  the  urine — the  so-called  'Mithnemic 
neurasthenia."     There  may  be   polyuria. 

The  diagnosis  is  made  by  the  grouping  of  a  variety  of 
neurasthenic  symptoms  without  actual  organic  disease.  In 
man\^  cases  the  diagnosis  is  rather  a  question  of  medical 
intuition. 

The  prognosis  is  good  if  the  exciting  cau.se  can  be 
removed  and  if  the  patient  is  in  such  a  financial  condition 
as  to  be  able  to  carr)'  out  the  necessary  treatment.  Many 
patients,  handicapped  from  birth  with  a  weak  nervous 
system,  do  well  only  when  no  demands  are  made  upon 
their  strength  ;  as  soon  as  any  emergency  arises  they  go 
under. 

Treatment. — The  most  important  indication  is  to  dis- 
cover the  cause ;  this  often  requires  an  intimate  and  personal 
knowledge  of  each  individual  patient.  Over-worked  busi- 
ness-men are  best  treated  by  rest  with  a  change  of  scene,  as 
by  a  trip  abroad.  Pleasant  ph}'sical  exercise  to  the  point 
only  of  moderate  fatigue  is  often  beneficial.  The  general 
nutrition  should  be  improved  in  every  way  by  proper  food, 
sufficient  sleep,  and  a  proper  amount  of  recreation,  and  by 
massage,  hydrotheraphy,  and  tonics.  The  drug  treatment 
of  these  patients  should  be  limited,  however,  as  much  harm 
is  done  by  over-dosing.  Stimulants  and  narcotics  are  to  be 
withheld,  as  habits  are  easily  formed.  In  severe  cases  the 
Weir-Mitchell  rest-cure  may  be  recommended. 

HYSTERIA. 

Etiology. — This  most  perfect  type  of  a  functional  malady 
is  the  product  of  advanced  civilization.  Unknown  among 
barbarous  nations,  it  reaches  its  highest  development  among 
the  French  people.  Hysteria  is  twenty  times  more  common 
in  women  than  in  men,  and  usually  appears  between  the 
ages  of  fifteen  and  twenty,  although  manifestations  may  con- 
tinue until  late  in  life.  In  many  cases  there  is  a  family  his- 
tory of  nervous  troubles.    With  or  without  such  an  inherited 


HYSTERIA.  80 1 

neurotic  predisposition,  hysteria  may  be  induced  by  injudi- 
cious training,  an  unstable  moral  organization,  or  a  lack  of 
self-control.  Among  more  direct  influences  are  emotions, 
unhappy  love  affairs,  domestic  worries,  sexual  excess, 
masturbation,  and  physical  enfeeblement  by  injury  or  acute 
disease.  In  some  cases  ovarian  or  uterine  disease  seems 
capable  of  originating  hysteria,  but  these  cases  are  much 
less  common  than  are  ordinarily  supposed.  Hysterical 
symptoms  may  spread  to  other  patients  by  sympathetic 
imitation,  or  "  moral  contagion  "  as  it  may  be  termed. 

Pathology. — There  is  no  organic  lesion  in  hysteria  ;  the 
condition  is  entirely  functional. 

Symptoms. — The  clinical  picture  of  hysteria  is  so  varied 
and  complex  that  only  a  brief  description  of  individual 
symptoms  can  here  be  given,  and  no  attempt  will  be  made 
to  evolve  a  general  picture  of  the  disease. 

I.  Motor  Symptoms. — {a)  Convulsive  Seizures. — A  mild 
and  a  severe  form  of  hysteria  are  recognized.  The  mild 
form  usually  appears  after  emotions.  The  patient  becomes 
"  hysterical,"  laughs  and  cries  alternately,  and  complains 
of  a  constricted  feeling  in  the  throat,  as  if  a  ball  were  rising 
into  it  ("  globus  hystericus").  There  may  even  be  painful 
sensations,  referred  to  some  internal  organ,  resembling 
sensory  aurae.  The  patient  then  falls  into  convulsions,  but 
not  as  suddenly  as  in  epilepsy.  The  convulsive  movements 
are  clonic  and  irregular.  The  attack  subsides  gradually, 
usually  with  the  passage  of  flatus  or  of  a  large  quantity  of 
limpid  urine,  and  the  patient,  as  a  rule,  has  no  recollection 
of  what  has  happened. 

The  severe  form,  or  hystero-epilepsy,  is  not  as  common 
in  America  as  in  France.  The  convulsions,  which  are 
usually  preceded  by  minor  hysterical  manifestations,  simulate 
true  epileptic  attacks  ;  but  they  last  longer,  the  tongue  is  not 
bitten,  and  the  movements  are  not  shock-like.  The  convul- 
sive seizure  is  usually  followed  by  emotional  displays,  by 
cataleptic  poses,  by  opisthotonos  Or  other  distortions,  and  by 
attitudes  and  grimaces  expressive  of  the  deepest  emotions. 
As  the  patient  emerges  from  the  condition  delirium  and 
hallucinations  are  not  uncommon,  or  the  patient  may  sink 


8o2        MAXCAL    OF   THE   PRACTICE    OF  MEDICLXE. 

into  a  prolonged  trance.  The  attacks  may  frequentl}'  be  re- 
peated, as  in  the  stains  cpilcpticus,  but,  unUke  that  condition, 
do  not  seem  to  exert  a  deleterious  effect  upon  the  general 
health., 

[li)  Paralysis  is  common  and  may  invoi\e  any  part  of  the 
motor  apparatus.  The  onset  may  follow  a  convulsive 
seizure  or  ma\-  be  induced  by  emotion.  The  jxaralj'sis  may 
be  hemiplegic,  paraplegic,  or  monoplegic.  Hemiplegia  is 
more  common  upon  the  left  side,  and  is  usually  associated 
with  hemianiijsthesia.  The  face  is  not  affected.  Hysterical 
paraplegia  is  the  most  common  form  of  paralysis,  and  the 
affected  muscles  may  be  flaccid  or  spastic.  There  may  be 
only  loss  of  power  for  certain  combined  movements  (as 
vi'alking),  while  the  patient  still  retains  the  power  to  move 
the  legs  in  bed.  The  reflexes  may  be  increased,  there  is 
irregular  voluntary  resistance  to  passive  motion,  and  a 
spurious  ankle-clonus  may  be  present.  The  muscles  do  not 
waste,  the  electrical  reactions  are  normal,  and  bed-sores  do 
not  occur.  The  feet  are  usually  extended  and  inverted. 
In  some  cases  ataxia  occurs,  with  paresis.  Other  hysterical 
manifestations  are  usually  combined  with  paresis,  forming 
a  more  or  less  characteristic  symptom-complex.  A  charac- 
teristic form  of  hysterical  paralysis  is  aphonia,  in  which  the 
voice  is  lost  or  reduced  to  a  whisper.  Examination  shows 
lack  of  approximation  of  the  vocal  cords  during  phonation, 
although  the  glottis  can  readily  be  closed  by  coughing.  In 
many  cases  hysterical  aphonia  complicates  acute  catarrhal 
laryngitis. 

(c)  Contractures  and  Spasms. — Contractures  maybe  hemi- 
plegic,  paraplegic,  or  monoplegic  in  type.  The  smaller 
joints  are  usually  flexed,  the  larger  joints  extended.  Ankle- 
clonus,  exaggerated  reflexes,  and  a  spastic  gait  are  com- 
monly present,  so  that  the  case  may  resemble  lateral  scle- 
rosis so  closely  that  a  differential  diagnosis  may  be  impos- 
sible. The  contractures  disappear,  however,  during  sleep 
and  during  chloroform-narcosis,  and,  although  usually  pro- 
tracted, tend  eventually  to  disappear  spontaneously.  Hys- 
terical trismus  is  not  uncommon.  Contractures  of  certain  of 
the  abdominal  muscles,  combined  with  relaxation  of  the  recti 


HYSTERIA.  803 

and  the  inflation  of  the  intestines  with  gas,  produce 
"phantom  tumors,"  which  in  some  instances  are  asso- 
ciated with  the  symptoms  of  spurious  pregnancy  or  even 
of  labor.  Phantom  tumors  readily  disappear  under  full 
anaesthesia. 

Clonic  spasms  are  not  uncommon,  and  are  generally 
rhythmic  in  character  ("  rhythmic  chorea,"  "  hysterical 
chorea  ").  Volitional  tremor  may  exist,  resembling  that  of 
insular  sclerosis. 

2.  Sensory  Symptoms. — {a)  Ancssthesia  is  exceedingly  com- 
mon, occurring  usually  in  irregular  areas  which  may  also 
be  insensitive  to  touch  and  devoid  of  the  muscular  sense. 
Hysterical  hemiansesthesia  is  so  characteristic  as  to  possess 
positive  diagnostic  value. 

{b)  HypcrcEstJiesia  may  give  rise  to  spontaneous  pain,  or 
merely  to  tenderness  upon  palpation.  Hyperaesthetic  areas 
are  rare  on  the  extremities,  but  are  common  on  the  head, 
especially  over  the  sagittal  suture.  This  pain  over  the 
vertex,  of  an  agonizing  character,  is  likened  to  the  pain 
which  would  be  experienced  if  a  nail  were  being  driven 
into  the  head,  hence  the  term  davits  hystericus  which  has 
been  applied  to  it.  Other  hyperaesthetic  areas  are  com- 
monly found  over  the  sternum,  under  the  mammae,  along 
the  vertebral  column,  and  over  the  ovaries.  If  pressure 
applied  to  these  hyperaesthetic  zones  induces  hysterical  mani- 
festations, the  zones  are  frequently  spoken  of  as  "  hystero- 
genic points."  Spinal  hyperaesthesia  may  affect  the  whole 
column  or  only  a  single  segment,  and  is  often  so  ex- 
treme that  the  slightest  touch  gives  rise  to  exquisite  pain. 
Abdominal  hyperaesthesia  may  simulate  gastric  ulcer,  ap- 
pendicitis, or  peritonitis.  In  the  latter  case  the  resemblance  is 
almost  perfect,  even  to  the  presence  of  fever  and  the  perito- 
neal facies.  Hyperaesthesia  of  the  breast  may  be  accom- 
panied by  a  diffused  swelling  of  the  gland,  but  the  hysterical 
breast  may  be  recognized  by  the  exquisite  superficial  ten- 
derness, by  constant  variations  in  the  swelling,  and  by  the 
recurrence  of  the  symptoms  at  the  menstrual  period  or  after 
exceptional  excitement  or  fatigue. 

3.  Special  Senses. — There  may  be  limitation  of  the  visual 


804        M.-LVr.lL    OF   THE   PA'ACT/CE    OE  MEDICEXE. 

field,  especially  for  colors,  or  there  may  be  hemianopia. 
The  color-sense  may  be  partially  or  completely  lost  (hyster- 
ical achromatopsia).  Loss  of  the  senses  of  smell  and  taste  are 
not  uncommon.  Hysterical  deafness  may  occur  alone  or 
may  alternate  with  attacks  of  hysterical  blindness.  Hyper- 
jEsthesia  of  the  eye  or  the  ear  may  also  occur,  the  former 
being  the  more  common. 

4.  Digestive  SytiiptoDis. — The  globus  hystericus,  or  the  feel- 
ing as  though  a  ball  were  rising  in  the  throat,  may  be  asso- 
ciated with  pharyngeal  spasm.  The  spasm  may  spread  to 
the  oesophagus,  so  that  swallowing  becomes  difficult  or  im- 
possible (see  Spasmodic  Stenosis  of  the  QEsophagus).  Hys- 
terical vomiting,  in  which  the  food  is  regurgitated  soon  after 
eating,  and  without  attendant  nausea,  may  persist  for  months 
without  marked  failure  in  nutrition.  An  antagonism  to  food 
{liystcrical  anorexia,  or  anorexia  nervosa)  may  occur  in  young 
girls,  and  may  be  so  marked  that  no  food  is  taken  for  days ; 
the  patient  finally  becomes  emaciated  to  an  extreme  degree, 
and  death  from  asthenia  may  result  in  rare  instances.  De- 
ception, however,  is  practised  in  the  vast  majority  of  these 
"  fasting  girls,"  food  being  taken  unobserved.  Depraved  appe- 
tite, dyspepsia,  and  gastric  pains  are  not  uncommon.  Peri- 
staltic unrest  (see  page  441)  may  also  occur.  Reversed  peri- 
stalsis has  occurred,  the  patient  vomiting  rectal  enemata  that 
have  been  previously  given.  Flatulency  is  common  and  dis- 
tressing. Nervous  diarrhoea  may  occur,  diarrhoeal  move- 
ments usually  being  induced  by  eating.  Constipation  is 
more  frequent,  and  may  be  so  obstinate  in  character  that 
the  bowels  do  not  move  for  weeks,  despite  energetic  medi- 
cation. Haematemesis  due  to  vaso-motor  disturbance  may 
undoubtedly  occur,  but  in  every  case  deception  should  be 
suspected. 

5.  Respiratory  Symptoms. — Rapid  breathing  (50  to  120  to 
the  minute),  without  increased  frequency  of  the  pulse  or  other 
symptoms  of  dyspnoea,  is  characteristic  of  hysteria.  Actual 
dyspnoea  may  attend  laryngeal  spasm,  and  suffocation  may 
seem  imminent.  H)'sterical  aphonia  has  already  been  al- 
luded to.  Extraordinary  cries  and  sounds,  resembling  those 
produced  by  animals,  may  be  emitted.     A  dry,  paroxysmal 


iiYS'jiijaA.  805 

barking-  cough  is  a  frequent  symptom  in  chlorotic  girls,  and 
may  spread  in  schools  by  unconscious  imitation.  Spurious 
haemoptysis  may  occur,  the  sputum  being  usually  pale-red 
in  color  rather  than  the  crimson  color  seen  in  true  hem- 
orrhage. In  these  cases  the  blood  comes  from  the  mouth 
or  the  pharynx.     In  other  cases  deception  is  practised. 

6.  Circulatory  Symptoms. — Cardiac  irritability,  palpitation, 
and  pain  over  the  heart  are  common  symptoms.  The  car- 
diac pain  may  give  rise  to  the  symptoms  of  pseudo-angina 
pectoris.  Hot  and  cold  flashes,  pallor,  and  flushings  with  a 
sensation  of  heat  result  from  vaso-motor  disturbance. 
Localized  flushings,  areas  of  circumscribed  cedema,  and 
similar  phenomena  may  occur.  Stigmata,  or  hemorrhages 
in  the  skin,  may  occur,  although  in  the  vast  majority  of 
cases  they  are  of  fraudulent  origin. 

7.  Urinary  Symptoms. — After  hysterical  manifestations 
the  urine  is  abundant,  limpid,  and  of  a  low  specific  gravity. 
Retention  of  urine  is  common ;  incontinence  is  unknown. 
The  urine  may  be  partially  or  completely  suppressed,  and 
this  hysterical  anuria  may  last  for  days,  during  which  time 
the  sweat,  vomit,  and  other  secretions  become  loaded  with 
urea.  It  is  a  characteristic  of  hysterical  anuria  that  ura^mic 
symptoms  do  not  appear.  Irritation  of  the  bladder,  shown  by 
a  constant  desire  to  pass  urine,  is  a  frequent  and  trouble- 
some symptom. 

8.  Joint-symptoms  (Brodie's  Joint). — The  larger  joints, 
especially  those  of  the  knee  and  the  hip,  are  usually  affected, 
and  the  symptoms  may  follow  slight  injuries.  The  joint  is 
swollen,  resists  passive  motion,  and  is  flexed,  although 
changes  in  position  occur  from  day  to  day.  The  skin  over 
the  joint  is  hyperaesthetic  and  usually  cool,  but  heat  may  be 
observed,  especially  at  night,  accompanied  with  pain.  Motion 
and*  handling  are  painful.  In  protracted  cases  the  muscles 
about  the  joint  may  waste.  In  rare  instances  organic 
changes  in  the  joint  may  succeed  the  functional  disturb- 
ance. 

9.  Temperature. — In  hysteria  the  temperature  is  usually 
normal,  although  in  severe  cases  a  slight  rise  may  be  ob- 
served.    Rare  cases  of  "  hysterical  fever  "  are  reported,  in 


8o6        M.IXC.IL    OF   TUK    J'RACriCl:    OF  MEDICIXE. 

which  a  periodic  elevation  of  temperature  to  102°  or  103° 
F.  has  been  recorded.  In  very  exceptional  cases  a  rise  to 
108°  or  110°  F.  has  been  noted,  but  these  high  tempera- 
tures "are  in  all  probability  fraudulent.  Cases  of  hysterical 
fever  with  .spurious  local  manifestations  arc  most  deceptive. 
The  occurrence  of  fever  with  hysterical  symptoms  resem- 
bling peritonitis  has  been  described.  Fever  with  pain  in 
the  head,  photophobia,  contracted  pupils,  vomiting,  and 
retraction  of  the  neck  ma}'  closely  resemble  meningitis. 

10.  Moital  Syiiiptonis. — There  is  usualh'  an  exaggeration 
of  ordinary  emotional  excitement.  The  moral  character 
becomes  changed ;  the  patient  becomes  low-spirited  and 
listless  or  inquisitive  and  fussy.  Often  the  patient's  attention 
is  morbidly  concentrated  upon  herself  Whims  of  the 
most  varied  kind  are  invented  from  time  to  time ;  the 
patients  show  a  marked  tendency  to  deceive  others,  evince 
a  wish  to  become  objects  of  notoriety,  and  not  the  slightest 
dependence  is  to  be  placed  upon  their  statements.  Other 
patients  become  sullen  and  refuse  to  answer  questions. 
Attacks  of  insanity  and  persistent  hallucinations  and  de- 
lirium may  occur.     Trance  or  catalepsy  may  develop. 

Prognosis. — The  danger  to  life  is  so  extremely  small 
that  it  may  be  disregarded.  The  duration  varies  according 
to  the  severity  of  the  symptoms,  the  moral  force  of  the 
patient,  the  duration  of  the  operative  cause,  and  the  home 
surroundings  and  environment. 

Treatment. — It  is  essential  that  the  physician  should 
gain  the  patient's  confidence  from  the  start,  and  that  he 
should  enter  into  every  detail  of  her  daily  life,  so  as  to  dis- 
cover what  elements  are  at  work  perverting  her  nervous 
forces.  Hysteria  arising  from  an  unhappy  home-life,  from 
disappointments  in  love,  and  from  kindred  causes  is  best 
treated  by  travel  and  total  change  of  environment.  In 
many  cases  routine  employment  is  to  be  recommended. 
The  physician  should  not  forget  that  the  patient's  complaints 
are  not  entirely  imaginary,  but  that  the  suffering  often  is 
real.  On  the  other  hand,  too  much  .sympathy  should  not 
be  given  by  either  physician  or  friends.  Many  patients  im- 
prove at  once  when  they  are  taken  from  fussy  and  solicitous 


SUN-S'l'h'Oh'K.  807 

relatives  and  placed  amonc^  strangers,  where  self-control 
must  of  necessity  be  exerted. 

The  general  health  must  be  improved  in  every  possible 
way.  The  diet  should  be  wholesome  and  abundant ;  exer- 
cise should  be  graded ;  and  sufficient  hours  for  rest  and 
sleep  must  be  insisted  upon.  Laxatives  and  other  medica- 
tion are  indicated  should  dyspeptic  symptoms  be  present. 
Bromide  of  sodium,  phenacetine,  valerian,  asafoetida,  and 
similar  antispasmodic  drugs  are  of  service  during  the  acute 
manifestations  of  the  disorder,  but  the  continuous  use  of 
these  remedies  as  a  routine  treatment  is  much  to  be  de- 
plored.    Morphine  should  never  be  used. 

In  severe  and  intractable  cases  the  Weir-Mitchell  rest- 
cure — a  combination  of  seclusion,  rest,  and  forced-feeding — 
may  be  recommended,  especially  for  under-nourished 
patients  with  marked  hysterical  manifestations,  and  for 
those  who  are  constantly  passing  over  the  limits  of  their 
nervous  strength,  A  bright,  intelligent  nurse  and  a  com- 
plete isolation  from  family  and  friends  are  essential  features 
of  this  treatment.  Rest  in  bed  for  three  or  four  weeks, 
with  daily  exercise  of  the  muscles  by  faradism  or  massage, 
usually  allows  the  strained  nervous  system  to  return  to  its 
normal  condition  and  improves  body-nutrition.  The  diet 
during  the  first  ten  days  is  to  be  milk  alone ;  later,  solid 
food  is  to  be  added  gradually. 

For  hysterical  vomiting  and  anorexia  nei'vosa  forced  feed- 
ing by  the  stomach-tube  is  to  be  employed.  During  a  con- 
vulsive attack  a  cold  douche  may  be  applied  to  the  head, 
with  the  assurance  to  the  family,  in  the  hearing  of  the 
patient,  that  there  is  no  danger,  but  that  the  cold  applica- 
tions will  be  continued  until  relief  is  experienced.  In 
many  instances,  however,  it  is  better  to  leave  the  patient 
alone  and  unnoticed  until  the  attack  subsides  spontaneously. 
The  treatment  of  hysterical  paralysis  by  hypnotic  sugges- 
tion has  occasionally  been  followed  by  brilliant  results. 

SUN-STROKE. 

Two  distinct  conditions  due  to  exposure  to  intense  heat 
are  encountered — heat-exhaustion  and  thermic  fever. 


8oS        MAXCAL    OF  THE   PRACTICE    OF  .VEP/C/XE. 

Heat-exhaustion  may  be  induced  by  exposure  te^  the 
hot  sun  or  to  any  great  artificial  heat,  as  in  engine-rooms. 
There  is  prostration  bordering  upon  collapse  ;  the  skin  is 
cool  and  clammy  ;  the  fece  is  pale;  the  pulse  is  rapid  and 
feeble;  the  temperature  is  regularly  subnormal.  The  onset 
of  s\-mptoms  ma\-  be  gradual,  or  may  be  so  abrupt  that  the 
patient  will  fall  in  .syncope.  In  severe  cases  the  conscious- 
ness may  be  lost  and  muttering  delirium  may  occur.  It  is 
thought  that  the  condition  is  dependent  upon  a  vaso-motor 
paresis  as  the  result  of  which  there  is  a  determination  of 
blood  from  the  surface  of  the  body  and  the  brain  to  the 
large  abdominal  blood-vessels. 

Treatment. — External  heat  should  be  applied,  prefer- 
ably by  the  hot  bath.  Stimulants  should  be  freely  admin- 
istered. 

Thermic  Fever  (Sun-stroke;  Heat-stroke;  Insolation; 
Coup  de  Soleil). — Etiology. — This  condition  is  most  fre- 
quent when  great  heat  is  combined  with  a  high  percentage 
of  humidity.  Excessive  bodily  fatigue  and  intemperance 
are  predisposing  factors. 

Pathology. — Rigor  mortis  occurs  early,  and  putrefac- 
tive changes  appear  rapidly.  The  blood  is  dark  and  im- 
perfectly coagulated.  There  are  parenchymatous  changes 
in  the  liver  and  kidneys.  The  lungs  are  intensely  con- 
gested. 

The  symptoms  may  begin  abruptly,  the  patient  falling 
unconscious  to  the  ground  ;  or  they  may  be  preceded  by 
pain  in  the  head,  nausea  and  vomiting,  vertigo,  dimness  of 
vision,  or  colored  vision.  When  first  brought  under  observa- 
tion the  patient  is  unconscious,  with  deep  stertorous  breath- 
ing and  a  rapid  bounding  pulse.  The  carotid  arteries 
pulsate  visibly.  The  skin  is  hot,  dry,  and  reddish.  Urine 
and  feces  are  usually  discharged  involuntarily.  The  eyes 
are  suffused,  the  pupils  are  variable,  sometimes  contracted, 
sometimes  dilated.  The  temperature  varies  between  io6° 
and  112°  F.,  the  average  maximum  height  being  about 
108°  F.  Convulsions,  muscular  rigidity,  and  temporary 
delirium  of  an  active  form  are  of  common  occurrence.     If 


SUN-STROKE. 


809 


f 

\      \       '.      \       '.','.       \       \      ',       '.      \       \      '. 

il^  ::::::::::::    : 

■^  ::•'::::::::    : 

M\  \\i\l\  ::.:: 

.  -^  .  .  -^ 

Hl;TMM:i:i: 

-telMilMi 

T:T^M|aHi:M 

T:-M:V:U!:  :: 

:;;;::■.:::  V    ::    : 

Fig.  73. — Temperature  chart  of  sun-stroke. 


the  patient  is  to  do  badly,  the  pulse  becomes  rapid  and 
irregular,  the  breathing  becomes  irregular  or  "  Cheyne- 
Stokes,"    and    death    oc-  ^^„,^ 

'  109  ys 

curs,  usually  within  from 
twenty  to  thirty-six  hours. 
In  very  severe  cases  coma 
and  heart  failure  may  cause 
death  within  a  few  hours; 
in  rarer  cases  instantane- 
ous death  may  occur. 

.A.  mild  form  of  heat- 
fever,  which  occurs  in 
tropical  countries  and  gives 
the  symptoms  of  a  con- 
tinued fever  resembling  ty- 
phoid, has  been  described 
under  the  terms  "  ardent 
continued  fever"  and 
"  thermic  continued  fever." 

SeqiLel(B  consist  of  (i)  inability  to  bear  exposure  to  heat 
without  headache  and  distress ;  (2)  pain  in  the  head,  that 
may  be  constant  for  months ;  (3)  mental  weakness  with 
nervous  irritability.  In  rarer  cases  insanity  or  chronic 
meningitis  may  result. 

The  prognosis  is  grave.  About  one-third  of  the  cases 
end  fatally. 

Treatment. — Immediate  reduction  of  the  body-tempera- 
ture is  most  urgently  indicated.  Cold  affusions  and  appli- 
cations of  ice  to  the  surface  must  be  resorted  to  without 
delay.  When  practical,  the  cold  bath  (50°  to  60°  F.)  should 
be  given ;  ice-water  enemata  may  be  serviceable.  When  a 
bath  cannot  be  secured,  the  value  of  an  ice-pack  cannot  be 
over-estimated.  The  cold  applications  are  to  be  continued 
until  the  temperature  is  well  under  control.  Internal  anti- 
pyretics are  not  as  serviceable  as  cold  hydrotherapy.  In 
very  severe  cases  free  venesection  may  be  resorted  to.  In 
convulsions  and  delirium,  morphine  is  to  be  given  hypo- 
dermically.    Stimulation  is  required  in  the  majority  of  cases. 


8lO        MAXC.IL    OF   T]IE   PRACTICE    OF  MEDICINE. 


DELIRIUM    TREMENS. 

Etiolog-y  and  Synonym. — Delirium  tremens  may  be  in- 
duced in  hard  drinkers  by  excesses,  by  sudden  withdrawal 
of  hquor,  by  fright,  shock,  or  acute  inflammation,  especially 
pneumonia.     Synoiiyjn  :  Mania  a  potu. 

Symptoms. — The  patient  becomes  tremulous,  nervous, 
and  is  unable  to  sleep.  Mental  depression  is  extreme. 
After  from  one  to  three  days  the  patient  passes  into  the 
characteristic  delirium,  with  visual  and  auditory  halluci- 
nations of  a  frightful  character.  The  temperature  ranges 
between  102°  and  103°  F. ;  the  pulse  is  rapid  and  soft; 
tremulousness  is  often  so  extreme  as  to  render  speech  inco- 
herent ;  insomnia  continues,  so  that  the  patient  will  get  no 
sleep  for  three  or  four  days.  The  condition  either  subsides 
in  three  or  four  days,  especially  after  an  induced  sleep,  or  the 
insomnia  persists,  the  pulse  becomes  more  rapid  and  feeble, 
the  delirium  becomes  of  a  low,  muttering  type,  and  death 
takes  place  from  asthenia  in  a  typhoid  condition.  Pulmon- 
ary congestion  and  oedema  may  complicate  fatal  cases. 

Diagnosis. — It  is  important  in  every  case  to  exclude 
local  inflammations,  especially  of  the  lung,  that  may  have 
been  the  exciting  cause  for  the  outbreak  of  the  delirium. 
A  careful  examination  of  the  lungs  should  be  made  every 
day,  as  delirium  tremens  may  be  simulated  by  the  delirium 
of  pneumonia  at  the  apex  of  the  lung. 

The  prognosis  is  generally  good,  only  about  10  per  cent, 
of  the  cases  being  fatal.  Recurrences  are  to  be  expected 
unless  the  patient  abandons  the  alcohol  habit.  Delirium 
tremens  complicating  pneumonia  usually  runs  a  fatal  course. 

Treatment. — The  great  object  of  treatment  is  to  procure 
sleep  and  to  support  the  patient's  strength.  The  moderate 
use  of  opiates  is  recommended,  but  large  doses  are  injurious. 
Alcohol  should  not  be  entirely  withdrawn  until  after  conva- 
lescence is  established.  Hydrotherapy  is  of  service  in  many 
cases  in  controlling  the  delirium.  Hyoscine  in  gr.  yiij  doses 
hypodermically  is  of  service  in  producing  sleep.  The  com- 
bination of  bromide  of  sodium,  chloral,  and  tinctures  of  dig- 


RAYNAUnS  DISEASE.  8ll 

italis  and  capsicum  is  used  in  many  hospitals,  as  in  tlie 
following : 

I^.    Chloral  hydrate,  gf-^i 

Sodium  bromide,  7,  ss  ; 

Tinct.  digitalis, 

Tinct.  capsici,  da.  tTL  v  ; 

Spir.  amnion,  aromat,        3j ; 
Aquae,  q.  s.  ad  o'j- — M. 

Sig.     Dose  every  two  to  three  hours. 

The  patient  should  be  (constantly  guarded  by  attendants 
night  and  day,  to  prevent  his  escape  or  injui-y.  If  necessary, 
he  should  be  tied  down  by  a  draw-sheet,  or  in  severe  cases 
the  strait-jacket  may  be  applied. 


7,  VASO-MOTOR  AND  TROPHIC  DISORDERS. 

RAYNAUD'S    DISEASE. 

This  vaso-motor  neurosis  presents  three  grades  of  inten- 
sity— local  syncope,  local  asphyxia,  and  local  or  symmetri- 
cal gangrene.    The  majority  of  cases  occur  in  young  women. 

Local  syncope,  the  most  common  form,  leads  to  coldness 
and  pallor  of  the  extremities  ("  dead  fingers,"  "  dead  toes  "), 
and  may  be  induced  by  cold  or  by  emotions.  The  affected 
parts  are  stiff,  but  are  rarely  painful.  The  condition  lasts 
for  a  variable  time  and  may  be  succeeded  by  local  asphyxia. 

Local  Asphyxia. — There  are  lividity  and  cyanosis  of  the 
affected  parts  (the  fingers,  toes,  ears,  nose),  with  numbness, 
swelling,  and  some  pain.  The  capillary  circulation  is  ex- 
ceedingly sluggish.  The  condition  may  follow  that  of  local 
syncope.  As  the  attack  wears  off,  the  affected  parts  become 
bright  red  from  over-active  circulation.  Severe  attacks  may 
be  followed  by  local  gangrene.  Recurrences  are  common, 
especially  during  the  winter  months. 

Local  or  Symmetrical  Gangrene. — Ecchymotic  spots  and 
vesicles  appear,  and  become  the  starting-point  for  a  dry 
gangrene  which  is  usually  remarkably  symmetrical.     The 


8l2        MA.yr.lL    0J-'   J'J/Jl    rK.UUCK    OJ-   MEDJCIXE. 

ears,  fingers,  and  toes  are  the  special  seats  of  selection.  The 
afifoction  nia}-  be  complicated  by  purpura  ha;morrhagica, 
intermittent  ha^moglobinuria,  peripheral  neuritis,  and  a  vari- 
ety "of  mental  and  cerebral  symptoms. 

Diagnosis. — The  disease  must  not  be  confounded  with 
the  dr\'  gangrene  due  to  obliterating  endarteritis. 

The  prognosis  is  good  except  in  the  extensive  forms  of 
gangrene  or  in  the  gangrenous  cases  complicated  b)'  pur- 
pura ha-Miiorrhagica. 

Treatment. — Exposure  to  cold  should  be  avoided,  and, 
if  possible,  the  patient  should  spend  the  winters  in  a  warm 
climate.  The  continuous  electrical  current  may  be  applied 
to  the  spine  and  the  extremities.  Internal  medication  seems 
to  exert  no  beneficial  effect  upon  the  disease. 

ACUTE  CIRCUMSCRIBED  CEDEMA. 

Etiology  and  Synonyms. — This  disorder,  which  is  often 
of  a  distinctly  hereditary  character,  may  be  induced  reflexly 
by  gastric  disorders.  Attacks  occur  in  some  instances  with 
remarkable  periodicity.  Nothing  further  is  known  of  its  cau- 
sation.   Syiionyvis :  Angio-neurotic  oedema;  Giant  urticaria. 

Pathology. — There  is  a  localized  vaso-motor  dilatation 
allowing  of  the  transudation  of  serum. 

Symptoms. — A  circumscribed  cedematous  swelling  oc- 
curs in  some  part  of  the  body,  more  commonly  on  the 
face  or  the  arms.  The  skin  is  pale  and  tense,  but  there 
may  be  redness  of  the  integument  resembling  that  of  an 
inflammatory  swelling.  Itching  and  burning  sensations 
usually  accompany  the  outbreak.  There  may  be  sudden 
and  fatal  oedema  of  the  glottis.  Gastro-intestinal  symptoms 
— nausea  and  vomiting,  very  severe  abdominal  pain,  and 
diarrhoea — usually  accompany  the  attacks.  Urticaria  may 
precede  the  outbreak. 

The  prognosis  is  good  unless  the  larynx  be  involved,  but 
recurrences  are  the  rule. 

Treatment. — A  general  tonic  treatment  is  usually  indi- 
cated, and  indigestion  and  over-eating  must  be  avoided; 
otherwise  the  treatment  is  unsatisfactory. 


MYXCEDEMA   AND    CRETINISM.  813 

FACIAL  HEMIATROPHY. 

Etiology  and  Synonym. — This  rare  condition  occurs 
more  often  in  men  than  in  women,  and  is  rare  after  the 
twenty-fifth  year.  Synonym :  Progressive  unilateral  facial 
atrophy. 

The  pathology  of  the  condition  is  at  present  undefined. 
The  disease  is  supposed  to  originate  from  involvement  of 
the  trophic  fibres  of  the  fifth  nerve. 

Symptoms. — A  small  area  of  atrophy  begins  in  the  skin, 
usually  of  the  cheek  or  the  chin,  and  spreads  to  involve 
half  the  face,  being  sharply  limited  by  the  median  line. 

The  deeper  structures,  including  the  bones,  participate  in 
the  atrophy,  although  the  muscles  may  undergo  but  little 
change.  The  left  side  of  the  face  is  the  one  usually  in- 
volved. Pains  and  peculiar  sensations  may  accompany  the 
earlier  stages  of  the  disease,  and  hemiatrophy  of  the  tongue 
and  of  the  palate  may  occur. 

Prognosis. — The  disease  progresses  slowly,  and  at  any 
time  the  process  may  be  arrested.  Actual  recovery  does 
not  occur,  but  the  disease  does  not  endanger  life. 

Treatment  is  ineffectual. 

MYXCEDEMA  AND  CRETINISM. 

Cretinism  is  the  infantile  form  of  myxcedema,  and  is  due 
to  congenital  absence  of  the  thyroid  gland.  The  symptoms 
are  identical  with  those  of  the  adult  form  of  myxoedema, 
modified  by  the  fact  that  mental  development  and  body- 
growth  are  both  arrested  (see  Fig.  74).  Cretinism  may  be 
endemic  or  sporadic.  Symptoms  may  appear  at  birth  or 
during  the  years  of  infancy. 

Myxoedema  is  much  more  common  in  women  than  in 
men,  and  may  be  hereditary.  The  name  "myxoedema"  is 
derived  from  the  peculiar  swelling  of  the  skin,  due  to  the 
development  of  a  myxomatous  new  growth.  The  swelling 
is  most  marked  over  the  face  and  hands,  but  may  become 
generally  distributed.  The  skin  and  subcutaneous  tissues 
are  thickened,  firm,  resilient,  and  do  not  pit  on  pressure. 
The  skin  is  dry  and  rough  ;  the  facies  is  characteristic ;  the 


8i4 


M.IXr.lL    OF   THE   PRACTICE    OF  MEDICIXE. 


hair  becomes  coarse  and  falls  out,  and  a  reddish  patch  is 
usuall)'  present  on  the  cheeks.  Physical  and  mental  weak- 
ness becomes  more  and  more  marked,  and  may  proceed  to 
dementia.      The    speech    is    slow   and    monotonous.      The 

temperature  is  usually 
subnormal.  Sensory 
s)'mptoms  of  a  subjective 
nature,  such  as  persistent 
unpleasant  taste  and 
smell,  may  be  present. 
The  course  of  the  dis- 
ease is  slowly  progres- 
sive, extending  over 
years.  Improvement 
under  treatment,  how- 
e\er,  is  to  be  expected. 
In  m)'xcedema  the 
tln-roid  gland  is  usually 
much  diminished  in  size, 
and  it  may  become  com- 
pletely atrophied  and 
con\-crted  into  a  fibrous 
mass.  The  most  gener- 
ally accepted  theory  is 
that,  by  reason  of  a  fail- 
ure in  the  function  of 
the  thyroid  gland,  certain 
injurious   substances, 

Fig.  74. — Spor.idic  cretinism.  1   •    1  1 

which  no  longer  can  be 
rendered  innocuous  by  the  gland,  collect  in  the  body. 

Operative  MyxLvdcuia  ;  CacJicxia  stniinipriva. — The  symp- 
toms of  m)^\■cedcma  occur  in  animals  and  in  men  after 
removal  of  the  thyroid  gland.  The  condition  follows  only 
a  certain  number  of  complete  extirpations  and  a  smaller 
number  of  partial  removals  of  the  gland.  Operative 
myxoedema  is  rare  in  this  countrw 

Treatment. — It  is  highly  important  that  patients  with 
myxcedema  should  be  kept  warm  and  be  well  guarded  from 
cold.     The  winters  should,  if  possible,  be  spent  in  a  warm 


ACROMEGALY.  815 

climate.  Much  good  can  be  done  by  hot  baths,  friction, 
and  massage.  The  functions  of  the  skin  should  be  kept 
active  byjaborandi  or  its  alkaloid  pilocarpine.  The  essential 
treatment  consists  in  thyroid-feeding  or  the  use  of  extracts 
from  the  fresh  thyroid  glands  of  sheep.  From  one-quarter 
to  one-half  of  a  gland  may  be  given  daily,  or  from  2  to  5 
grains  of  the  "  desiccated  thyroid  "  of  any  reliable  maker. 
Care  should  be  taken  in  ordering  larger  doses  than  these, 
as  dangerous  symptoms  of  over-dosing  may  ensue. 

SCLERODERMA;    SCLEREMA. 

The  causes  of  sclerema  are  unknown,  although  the  disease 
is  classed  among  the  tropho-neuroses.  The  majority  of 
cases  occur  in  women  of  middle  life.  The  lesion  consists 
in  the  circumscribed  or  diffused  production  of  connective 
tissue  in  the  skin.  The  skin  becomes  hard,  rigid,  and  ad- 
herent to  the  subcutaneous  tissue.  Pressure  upon  the 
underlying  muscles  may  interfere  with  their  action  and 
may  result  in  a  certain  amount  of  atrophy.  Hyperaemia 
of  the  skin  during  the  earlier  stages  may  be  followed  by 
pigmentation  or  by  atrophy  of  the  pigment.  The  circum- 
scribed form  of  sclerema  is  known  as  "  morphoea "  or  as 
"  Addison's  keloid."  The  diffuse  form  may  involve  large 
portions  of  the  body,  rendering  motion  difficult. 

The  disease  may  develop  slowly  or  rapidly,  but  when  de- 
veloped the  lesions  tend  to  persist  for  months  or  years. 
Recovery  may  occur,  but  in  most  instances  the  disease  after 
a  certain  length  of  time  becomes  no  longer  progressive. 

Massage,  oil-inunctions,  galvanism,  avoidance  of  cold,  and 
a  tonic  regimen  constitute  the  essential  points  in  the  treat- 
ment. 

ACROMEGALY. 

Etiology. — Acromegaly  occurs  in  both  sexes  during 
youth  and  middle  age.  The  etiology  of  the  disease  is 
unknown. 

The  patholog-y  is  undetermined.  Hyperplasia  of  the 
pituitary  body  is  an  almost  constant  lesion,  but  it  is  also 
known  that  similar  conditions  of  that  structure  may  exist 


8l6        J/.LVr.-lL    OF   THE   PMACriCE    OF  MEDICINE. 

without  acromeg^ah-.  In  some  of  the  reported  cases  there 
has  been  pershstence  of  the  thymus  gland. 

Symptoms. — The  hands  and  feet  become  enormously 
enlarged,  owing  chiefly  to  hypertroph\'  of  the  bones,  al- 
though the  muscles,  skin,  and  subcutaneous  tissues  also 
undergo  h\-pertr(iph\'.  The  nose  becomes  enlarged  in  all 
dimensions,  and  the  lower  portions  of  the  face  are  strikingly 
increased  in  size,  so  that  the  lower  jaw  usually  projects  far 
be\-ond  the  line  of  the  upper  teeth.  lI}-pertroplu'  of  the 
tongue  occurs  in  well-marked  cases.  The  bones  of  the 
thorax  may  also  become  enlarged,  and  the  back  may  be  so 
bowed  that  the  chin  rests  upon  the  sternum.  Sensory  and 
vaso-motor  symptoms  of  varied  character  attend  the  disease, 
and  there  may  be  persistent  headache.  The  muscular 
strength  is  generally  poor. 

A  condition  allied  to  acromegal)'  has  been  described  by 
Marie  under  the  name  of  hypertrophic  puluioiiary  osteo- 
arthropathy, this  form  being  associated  with  pulmonary 
lesions.  The  condition  differs  from  acromegaly  in  the  fol- 
lowing particulars:  (i)  The  lower  jaw  is  not  enlarged;  (2) 
the  articular  ends  of  the  bones  are  so  enlarged  as  to  interfere 
somewhat  with  the  mobility  of  the  joint ;  (3)  there  is  a 
peculiar  bulbous  deformity  of  the  terminal  phalanges. 

Treatment  is  inoperative. 


IX.  DISEASES  OF  THE  MUSCLES. 


MYOSITIS. 


Primary  Myositis. — The  few  recorded  cases  of  this  disease 
have  been  characterized  by  sweUing  and  tenderness  of  the 
muscles,  stiffness  and  pain  on  motion,  and  oedema  of  the 
subcutaneous  tissues.  Atrophy  of  the  muscles  may  result. 
The  process  may  terminate  fatally  by  involving  the  muscles 
of  deglutition  and  of  respiration.  The  spleen  is  enlarged, 
and  an  irregular  erythematous  eruption  is  usually  present, 
the  disease  resembling  an  acute  infection  in  these  respects. 
Examination  of  the  affected  muscles  shows  marked  degen- 
eration of  the  fibres,  with  an  infiltration  of  the  interstitial 
tissue.  The  course  of  the  disease  extends  over  several 
months  or  years.  The  diagnosis  from  trichinosis  can  be 
positively  made  only  by  microscopic  examination  of  the 
muscle-fibres.     No  curative  treatment  is  known. 

Acute  purulent  myositis,  which  is  usually  a  complication 
of  pyaemia,  more  rarely  of  other  septic  diseases,  has  occurred 
as  a  primary  form  in  a  few  instances. 

Progressive  myositis  ossificans  is  a  rare  disorder  in  which 
the  muscles  undergo  ossification.  The  process  may  be 
limited  to  certain  muscles,  or  may  be  more  generally  dis- 
tributed, as  in  the  well-known  case  of  the  "  ossified  man." 

PROGRESSIVE  MUSCULAR  DYSTROPHY. 
Etiology  and  Synonyms. — This  disorder  of  development 
is  inherited,  chiefly  through  the  mother,  in  three-fifths  of  the 
cases,  and  usually  appears  before  the  tenth  year,  although 
its  onset  may  be  deferred  until  the  twentieth  or  the  twenty- 
fifth  year.  The  disease  is  four  times  as  common  in  boys  as 
in  girls.  The  etiology  of  the  disease  is  unknown.  Syno- 
nyms :  Idiopathic  muscular  atrophy ;  Pseudo-hypertrophic 
muscular  paralysis. 

52  817 


8l8        MA.\r.4L    OF   THE   PK\lC'riCE    OF  MEDICINE. 

Pathology. — There  is  an  increase  of  connective  tissue, 
and  Lisualh'  an  increased  deposit  of  f\t  about  the  muscular 
fibres.  The  muscular  fibres  become  hypertrophied  and 
their  nuclei  are  increased  in  number.  Degeneration  of  the 
fibres  then  ensues,  and  leads  to  atrophy,  so  that  in  advanced 
stages  the  muscles  resemble  masses  of  adipose  tissue.  A 
primary  muscular  atrophy  may  occur,  with  or  without  the 
development  of  dense  connective  tissue  and  of  fat  about  the 
atrophied  muscles.  The  spinal  cord  and  the  peripheral 
nerves  are  normal,  the  disorder  being  a  primary  disease  of 
the  muscles. 

Symptoms. — According  to  the  relative  proportion  of 
hypertrophy  or  atrophy  of  muscular  fibres,  three  clinical 
forms  are  described : 

I.  Pscudo-Jiypcrtropliic  vuisciilar  paralysis  is  the  form  in 
which  increased  connective  tissue  and  fatty  deposits  are 
associated  with  atrophy  and  degeneration  of  the  muscle- 
fibres.  The  first  symptoms  noted  are  a  weakness  of  the 
muscles,  usually  of  the  calves,  and  an  increase  in  their 
apparent  bulk.  The  gait  becomes  awkward  and  clumsy, 
and  there  is  difficulty  in  mounting  stairs.  The  characteristic 
method  of  rising  from  the  floor  is  by  placing  the  hands  on 
the  knees  and  "  climbing  up  the  legs."  The  infraspinatus, 
the  biceps,  and  the  triceps  muscles  may  be  affected  in  like 
manner.  The  knee-jerk  is  normal ;  the  reaction  of  degener- 
ation is  not  obtained.  Later  in  the  disease  shrinkage  of  the 
muscle-bulk  occurs,  with  deformities.  Death,  when  it  occurs, 
is  due  to  some  intercurrent  disease. 

2.  Hypertrophic  paralysis  is  the  form  in  which  the  muscles 
undergo  at  first  a  true  hypertrophy,  but  become  atrophied 
late  in  the  disease.  The  symptoms  are  practically  identical 
with  those  of  the  pseudo-hypertrophic  form. 

3.  T\iQ  primary  atrophic  form  differs  from  the  preceding 
forms  only  in  the  absence  of  a  primary  enlargement  of 
muscle-bulk.  A  number  of  varieties  of  this  form  are 
described,  according  to  the  distribution  of  the  lesions.  Of 
these  varieties  the  following  are  the  most  important : 

{a)  The  infantile  form,  or  the  Landouzy-Dejerine  type,  in 
which  the  face  and  the  shoulder-girdle  are  affected. 


JV/OA/SKN'S    DISEASE;    MYOTONEi    CONGENITA.    819 

[b)  T\vQ  jitvcnile  form  of  Erb,  in  which  the  affection  first 
appears  between  the  fifteenth  and  twentieth  years,  and  in- 
volves the  muscles  of  the  shoulder,  upper  arm,  gluteal 
region,  and  thigh. 

Prog-nosis. — The  course  of  the  disease  extends  over  years  ; 
the  disease  progresses  steadily,  and  the  outlook  is  bad. 

Treatment  is  without  influence  on  the  disease.  Galvan- 
ism and  oil-inunctions  with  friction  may  be  tried.  The 
general  health  must  be  improved  in  every  way. 

PARAMYOCLONUS  MULTIPLEX  (MYOCLONUS 
MULTIPLEX). 

This  rare  disease  occurs  usually  in  adult  males,  and  may 
be  induced  by  fright,  injury,  or  emotion. 

The  pathology  is  unknown  ;  the  disease  is  supposed  to 
be  allied  to  convulsive  tic. 

The  symptoms  consist  of  sudden  paroxysmal  contrac- 
tions, of  a  clonic  character,  of  a  number  of  muscles ;  the 
patient  may  be  thrown  from  a  chair  or  from  the  bed  by  the 
violent  tremors.  The  spasms  are  regularly  bilateral.  The 
most  characteristic  spasms  occur  in  the  muscles  of  the 
trunk  and  hips,  but  the  arms,  legs,  and  face  also  may  be 
involved.  In  exceptional  cases  the  spasms  assume  a  tonic 
form.  Between  attacks  there  may  be  a  general  muscular 
tremor.  The  body-strength  is  usually  unimpaired,  although 
neurasthenic  or  hysterical  symptoms  may  be  present. 

Paramyoclonus  is  to  be  diagnosed  from  hysteria  by  the 
fact  that  the  affected  muscles  are  not  physiologically 
allied,  and  therefore  the  spasmodic  movements  cannot  be 
imitated  voluntarily. 

Treatment. — Chloral  and  hyoscine  may  be  employed, 
together  with  a  tonic  treatment.  Hydrotherapy  seems  to 
do  good  in  some  instances. 

THOMSEN'S  DISEASE;    MYOTONIA  CONGENITA. 

This  disorder,  which  is  exceedingly  rare  in  America,  is 
practically  always  hereditary,  and  appears  in  childhood. 
It  is  unknown  whether  the  disease  is  a  primary  disease  of 
the  muscles  or  a  congenital  defect  in  their  innervation. 


820        M.tXL.iL    OF   7///;    PA'ACJ/CF    OF  MFDJCIXE. 

The  symptoms  consist  of  painless  tonic  spasms,  lasting 
for  a  few  seconds,  w  henever  voluntary  motion  is  attempted. 
Voluntary  muscular  contraction  and  relaxation  are  therefore 
slow,  and  the  muscles  seem  to  act  stiffly.  The  muscles 
limber  up,  however,  after  repeated  use,  but  the  spasms  are 
increased  by  cold  or  nervousness.  The  electrical  and 
mechanical  excitability  of  the  muscles  is  increased,  and  the 
muscles  themselves  may  undergo  hypertrophy,  but  the 
bodily  strength  is  not  always  good.  The  disease,  though 
incurable,  does  not  tend  to  shorten  life. 

There  is  no  treatment  for  the  disease,  although  Thomsen 
himself  obtained  benefit  from  active  muscular  exercise. 

Congenital  paramyotonia  is  a  primary  muscular  affec- 
tion, of  a  congenital  and  inherited  character,  in  which 
tonic  spasms  are  induced  by  exposure  to  cold.  The  spasms, 
which  may  occur  in  the  extremities  or  in  the  face,  may  last 
from  fifteen  to  twenty  minutes.  There  is  no  known  treat' 
ment  for  this  disease. 


X,  ANIMAL  PARASITES. 


TREMATODBS. 

1.  Distonia  hcpaticuni  (Fig.  75),  or  "liver-fluke,"  is  a  rare 
parasite  28  mm.  long  and  12  mm.  broad.  Its  habitat  is  the 
small  intestine,  but  it  may  enter  the  bile-passages  and  cause 
ascites  and  jaundice,  with  enlargement  of 

the  liver  and   chronic    inflammation  of 
the  biliary  passages. 

Distonia  lanceolatinn  is  a  smaller 
variety  infecting  cattle  and  sheep.  Dis- 
tonia endcmicwn  and  distonia  peruiciosum 
are  liver-flukes  endemic  in  Japan. 

2.  BilJiarzia  licematobia^  or  "  blood- 
fluke,"  endem.ic  in  Egypt,  Arabia,  and 
Northern  Africa,  is  the  cause  of  the 
"endemic  haematuria"  of  these  countries. 
It  is  found  in  the  abdominal  veins,  espe- 
cially the  portal,  splenic,  renal,  and  mes- 
enteric, and  is  more  commonly  found  in 
children.  Haematuria,  anaemia,  and  pain- 
ful and  frequent  micturition  are  the  usual 
symptoms.  The  great' majority  of  pa- 
tients recover,  and  the  symptoms  usually 
disappear  at  the  time  of  puberty. 

3.  Distonia  Ringcri,  or  the  "  bronchial  fluke,"  gives  rise  to 
cough  and  haemoptysis.  The  parasite  is  endemic  in  China 
and  Japan. 


Fig.  75. — Distoma  hepat- 
icum  (Vonjaksch). 


NEMATODES. 

ASCARIS    LUMBRICOIDES. 

Ascaris   lumbricoides,  or  round  worm,  resembles  in  ap- 
pearance the  ordinary   earth-worm.      The   female  is  from 

821 


822        M.lXr.lL    OF   77/J-:    PKACT/CE    OF  MEDICIXE. 

12  to  1 6  inclies  in  length,  tlie  male  about  8  inches.  This 
common  parasite  is  especially  frequent  in  Eastern  countries, 
in  women  and  children  and  in  the  insane.  The  habitat  of 
the  worm  is  in  the  small  intestine,  and  the  number  varies 
from  one  to  man\-  hundreds.  The  parasite  is  usually  passed 
by  the  rectum,  but  in  rare  cases  the  worms  may  wander 
into  the  bile-ducts  or  into  the  stomach,  from  which  they 
may  be  vomited,  or  may  pass  upward  to  enter  the  larynx, 
bronchi,  nares,  or  even  the  Eustachian  tube. 

The  symptoms  are  usually  mild  and  obscure.  There 
may  be  vague  s\'mptoms  of  gastro-intestinal  irritation,  or 
reflex  symptoms,  such  as  itching  of  the  nose,  grinding  of 
the  teeth,  or  broken  sleep.  In  children  convulsive  seizures 
due  to  worms  are  less  common  than  is  usually  supposed. 

The  diagnosis  can  be  made  with  certainty  only  by  the 
actual  passage  of  a  worm. 

Treatment. — Santonin  may  be  given  in  doses  of  from  ^ 
to  I  grain  three  times  a  day  to  a  child  of  five  years.  Larger 
proportional  doses  may  be  given  to  adults,  and  the  drug 
may  advantageously  be  combined  with  small  doses  of 
calomel.  Yellow  vision,  discolored  urine,  and  slight  delirium 
may  attend  the  use  of  santonin  in  susceptible  patients. 
When  these  symptoms  occur  the  drug  should  at  once  be 
discontinued.  Of  equal  service  are  the  fluid  extracts  of 
senna  and  spigelia  in  equal  parts,  3ss-j  of  the  admixture 
being  given  three  times  a  day  until  free  purgation  occurs. 

OxYURis  Vermicularis  (Pin -WORM;  Thread-worm). 

The  female  worm  is  from  lO  to  I2  millimeters  long;  the 
male  is  one-third  as  long.  The  habitat  is  in  the  ileum  and 
the  large  intestine ;  in  these  situations  the  parasite  gives  no 
symptoms.  If  the  rectum  be  invaded,  itching  and  burning 
of  the  anus,  worse  at  night,  occasion  much  distress.  Excita- 
tion of  the  sexual  organs  may  also  result.  The  parasite 
may  emigrate  into  the  vagina  and  produce  itching  and 
inflammation. 

The  diagnosis  is  made  by  finding  the  worms  in  the  de- 
jections, and  occasionally  on  the  skin   of  the  anal  region. 

The  treatment  consists  o^  rectal  injections  of  lime-water, 


TKJCJI/NA    SPIRALIS.  823 

infusion  of  quassia,  iced  salt-water,  bichloride  of  mercury 
(i  :  10,000),  or  solution  of  alum  (oj  :  Oj). 

Anchylostoma  Duodbnale. 

This  worm  {Strongylus  dtiodenalis)  is  found  in  the  upper 
portions  of  the  small  intestine,  and  is  most  common  in 
Egypt,  Italy,  and  Brazil.  The  parasite  is  almost  unknown 
in  the  United  States.     The  worm  attaches  itself  by  claw- 


a       0 

/I 


Fig.  76. — Anchylostoma  diiodenale  (Von  Jaksch)  :  a,  male,  l>,  female,  natural  size  ;  c,  male, 

enlarged. 

like  teeth  to  the  intestinal  wall,  and  sucks  blood  from  the 
blood-vessels.  The  symptoms  consist  of  digestive  disorders 
and  progressive  anaemia  ("  Egyptian  chlorosis  ; "  "  St.  Go- 
thard's  disease  "). 

Treatment. — Thymol  should  be  given  in  30-grain  doses 
in  capsule,  the  dose  to  be  repeated  in  two  hours  and  followed 
by  a  brisk  purgative. 

Trichocephalus  Dispar  (Whip- worm). 

This  parasite,  which  is  from  ^  to  2  inches  long,  is  cha- 
racterized by  a  filiform  anterior  portion  which  occupies  two- 
thirds  of  the  entire  length.  The  posterior  portion  is  blunt 
and  curved.  Its  habitat  is  in  the  caecum,  where  the  parasite 
is  frequently  found  in  great  numbers.  The  worm  possesses 
no  clinical  significance. 

Trichina  Spiralis. 
When  raw  or  imperfectly  cooked  ham  or  pork  contain- 
ing muscle-trichinae  is  taken  into  the  human  stomach,  the 
undeveloped  trichinae  are  liberated.  The  parasites  become 
perfectly  developed  by  the  third  day,  appearing  as  small 
silvery  threads  barely  visible  to  the  naked  eye.  New-born 
trichinae  migrate  into  the  muscles  by  the  sixth  day,  and 
there  assume  a  spiral  form  and  become  encysted,  the  cap- 
sule being  composed   of  connective  tissue  which  may  be 


824        M.LXf.lL    OF   THE   PRACTICE    OF  MEDICIXE. 


infiltrated  by  linic-salts.     ]\Iusclc-trichina;  so  encapsulated 
HKw  li\e  for  years. 

Symptoms  of  trichinosis  appear  if  trichina:  are  ingested 
in  any  considerable  number.  The  symptoms  appear  in  two 
stages : 

I.  Gastro-iutcstinal  symptoms  occur  one  or  two  clays 
after  the  ingestion  of  the  infected  ham.  There  are  nausea, 
vomiting,  abdominal  pain,  and  serous  diar- 
rhoea. In  severe  cases  the  symptoms 
may  resemble  cholera.  There  may  be 
considerable  fever.  In  this  stage  very 
severe  cases  may  terminate  fatally. 

2.  Muscular'  symptoms  develop  in  from 
one  to  two  weeks.  The  muscles  become 
swollen,  tender,  and  excessively  painful; 
the  skin  over  the  affected  muscles  is  usu- 
ally cedematous.  Involvement  of  the 
respiratory  muscles  leads  to  impairment 
of  respiratory  power,  dyspnoea,  and 
liability  to  bronchitis  and  broncho-pneu- 
monia. G^ldema  of  the  cN'elids  usually 
appears  by  the  seventh  day,  and  is  the 
most  characteristic  of  the  early  .symp- 
toms. Fever  of  an  irregular  type  is  usu- 
ally present,  and  profuse  sweating  is  com- 
monly observed.  Albuminuria  occurs  in 
the  majority  of  cases.  The  knee-reflexes 
are  usually  lost. 

The  diagnosis  is  aided  by  the  fact  that 
a  number  of  individuals  are  usually  affected  at  the  same 
time.  In  doubtful  ca.ses  a  small  piece  of  muscle  may  be 
excised  under  cocaine-anaesthesia  and  examined. 

The  duration  of  the  acute  symptoms  is  from  two  to  eight 
weeks.     Recovery  is  slow  and  tedious. 

The  prognosis  is  grave,  30  per  cent,  of  the  cases  termi- 
nating fatally,  chiefly  by  pulmonary  complications. 

Treatment. — Prophylactic  treatment  consists  in  the  gov- 
ernmental inspection  of  ham  and  pork  and  the  thorough 
cookin":  of  the  meat. 


Fig.  77. — Male  intesti- 
nal trichina  {a)  ;  female 
intestinal  trichina  (F)  ; 
muscle-trichina  (c)  (Von 
Jaksch). 


FILARIA    SANGUINIS  I/OMINIS.  825 

During  the  gastro-intestinal  stage  brisk  purgatives  should 
be  administered.  The  use  of  glycerin  in  5ss  doses  every 
hour  has  been  recommended.  Thymol  in  3j  doses  in  cap- 
sule is  also  of  service.  When  migration  into  the  muscle  has 
occurred  the  treatment  can  only  be  palliative. 

FiLARiA  Sanguinis  Hominis. 

The  adult  worm  is  from  4  to  5  inches  long,  and  in  the 
human  subject  probably  lodges  in  some  large  lymphatic 
vessel.  The  female  produces  an  enormous  number  of  em- 
bryos from  Y2Q  to  tV  °^  ^"^  '"^^  ^oJ^g  sri<J  o^  the  width  of  a 
red  blood-cell.  The  embryos  enter  the  blood-current,  and 
are  present  in  the  blood  during  the  night,  but  disappear 
during  the  day-time.  Should  the  patient  sleep  during  the 
day  and  work  at  night,  the  migrations  of  the  parasites 
become  diurnal.  It  is  supposed  that  infection  occurs 
through  the  agency  of  mosquitoes.  The  parasite  is  most 
common  in  tropical  and  sub-tropical  countries. 

Symptoms  are  caused  by  the  blocking  of  the  lymph- 
channels  by  the  adult  worm  or 
the  ova.  Haematochyluria  (or 
chyluria)  is  the  most  common 
symptom.  The  passage  of  chy- 
lous urine  with  or  without  the 
admixture  of  blood  is  inter- 
mittent and  is  not  inconsistent 

with     good      general     health.  Fig.  rS.-Filaria  sanguinis  hominis 

^  ^  (Von  Jaksch). 

Among   the    other    symptoms 

may   be    mentioned    lymph-scrotum,    chylous    hydrocele, 

chylous  ascites,  and  elephantiasis. 

The  diagnosis  of  parasitic  chyluria  from  the  non-para- 
sitic form  is  made  by  the  finding  of  the  embryos  in  the  blood 
drawn  about  midnight. 

The  prognosis  is  generally  favorable. 

Treatment. — Gallic  acid  (sj-ij  doses  daily)  and  large 
doses  of  potassium  iodide  have  been  of  service.  The  treat- 
ment by  methyl-blue  has  apparently  been  followed  by  good 
results. 


826 


MAXr.-lL    OF   TITF    PKACTICF.    OF  MFDICIXE. 


CESTODES  (T^NI^;    TAPE-T^ORMS). 

When  the  cgi^s  of  the  ta,Miia  enter  the  stomach  of  animals 
the  embryos  become  hberated  :  they  then  migrate  to  other 

organs,  where  they  form  en- 
cj'sted  larva.'  or  scolices,  known 
as  "  cysticerci."  A  cysticercus 
is  therefore  an  undeveloped 
tape-worm.  Meat  containing 
CN'sticerci  is  said  to  be  "  measly," 
and  if  eaten  raw  or  imperfectly 
cooked  the  cysticerci  develop 
into  mature  form  within  the 
alimentary  canal  of  their  host. 
Three  chief  varieties  of  tape- 
worm are  encountered  in  the 
human  subject. 

1.  Tceiiia  soliii))i  is  from  6  to 
8  feet  long.  The  head,  which 
is  the  size  of  the  head  of  a 
pin,  is  marked  by  four  suckers 
and  a  double  row  of  hooklets. 
The  neck  is  about  an  inch  long. 
The  joints  or  proglottides, . 
which  contain  male  and  female 
organs  of  generation,  become 
larger  and  more  mature  the 
further  they  are  from  the  head. 
Taenia  solium  is  usually  single, 
and  develops  in  man  from  eat- 
ing measly  pork  or  ham. 

2.  Tee  Ilia  sagiiiata  or  mcdio- 
caiicllata,  which  is  the  most 
common  form  in  the  United 
States,  develops  from  eating 
measly    beef       The    worm    is 

longer  than  the  tajnia  solium,  and  the  sexual  apparatus  of 
the  mature  segments  is  somewhat  different.  The  head 
possesses  four  suckers,  but  no  hooklets. 


Fig.  79. — Small  portions  from  different 
parts  in  the  length  of  a  tape-worm ; 
natural  size  (Griffith). 


ECIIINOCOCCUS  D/SEASE.  ■     82/ 

3.  BotJiriocephaliis  laius,  which  is  common  in  the  German 
Baltic  provinces  and  rare  in  the  United  States,  develops 
from  eating  infected  fish.  The  head  is  club-shaped,  with 
two  slit-like  suckers  on  the  side.  The  segments  are  short 
but  broad,  and  the  parasite  frequently  grows  to  a  length  of 
from  25  to  30  feet. 

Symptoms  are  indefinite.  There  may  be  digestive  dis- 
turbances, abdominal  pain,  diarrhoea,  and  inordinate  appetite. 
The  patient  may  lose  flesh  and  strength.  There  may  be 
reflex  phenomena — itching  of  the  nose,  salivation,  nervous 
vomiting,  and  great  mental  depression.  The  diagnosis  can 
be  made  with  certainty  only  by  finding  the  links  in  the 
dejecta. 

The  growth  of  the  bothriocephalus  latus  is  frequently 
accompanied  by  progressive   anaemia. 

Treatment  is  successful  only  when  the  head  of  the  worm 
is  passed.  In  all  cases  the  patient  should  be  ordered  a  very 
light  diet  for  two  days  ;  a  saline  purgative  should  be  given 
on  the  second  night,  and  the  next  morning  the  taeniafuge 
should  be  given  on  a  fasting  stomach  and  followed  in  two 
hours  by  a  brisk  purge. 

Among  the  efficient  anthelminthics  recommended  are 
fluid  extract  of  male  fern  (3ij  dose),  infusion  of  pome- 
granate (2  to  3  ounces  of  the  bark  in  Oj  of  water),  infusion 
of  pumpkin-seeds,  and  koosso  (Jss  of  the  dried  flowers  in 
water).  Tanret's  tannate  of  pelletierine  may  be  given  in  a  5- 
to  lo-grain  dose,  but  the  remedy  is  very  expensive.  Good 
results  have  followed  3ss  doses  of  oil  of  pine-needles  given 
in  emulsion  or  in  capsule. 

ECHINOCOCCUS  DISEASE. 

(See  Hydatids  of  the  Liver^ 

For  the  rarer  forms  of  animal  parasites  the  reader  is  re- 
ferred to  larger  works. 


INDEX. 


Abdominal  aorta,  aneurysm  of,  263 
dropsy,  507 

wall,  liver  abscess  and,  529 
Aborted  typhoids,  32 
Abscess,  perinephritic,  606 

perityphlilic,  468 
Acetonuria,  571 
Acholia,  541 

Achromatopsia,  hysterical,  804 
Acromegaly,  815 
Actinomycosis,  164 
alimentary,  1 65 
cerebral,  165 
cutaneous,  165 
pulmonary,  165 
treatment,  166 
Addison's  disease,  664 
treatment,  666 
keloid,  815 
Agraphia,  696 

Ague-cake  in  malaria,  143,  147 
Air-hunger  in  typhoid  fever,  27 
Albuminuria,  561 
cyclic,  562 
febrile,  562 
functional,  561 
spurious,  561 

with  gross  renal  lesions,  562 
Amaurosis,  uremic,  587 
American  gout,  569 
Amyloid  degeneration  in  syphilis,  1 28 
Anaemia,  647 

in  pseudo-leuksmia,  661 
nervous,  437 
pernicious,  652 
diagnosis,  654 
symptoms,  654 
treatment,  655 
secondary,  647 
diagnosis,  649 
treatment,  650 
spinal,  719 
toxic,  647 
Anaemic  necrosis,  230 
Anaesthesia  dolorosa,  749 

in  hysteria,  803 
Anchylostoma  duodenale,  823 
Aneurysm,  256 

of  abdominal  aorta,  263 

of  thoracic  aorta,  diagnosis,  261 


Aneurysm  of  thoracic  aorta,  physical 
signs,  259 
treatment,  262 
symptoms,  257 
Angina  pectoris,  242 

treatment,  244 
Animal  parasites,  821 
Anorexia,  hysterical,  804 
treatment,  807 
nervosa,  804 
treatment,  807 
Anosmia,  751 
Anthracosis,  318 
Anthrax,  151 

external  form,  152 
internal  form,  153 
intestinal  form,  153 
Antipneumotoxine,  308 
Antitoxine,  diphtheric,  105 
Aorta,  abdominal,  aneurj'sm  of,  263 
thoracic,    aneurysm    of,    symptoms, 
257 
Aortic  orifice,  stenosis  of,  251 
regurgitation,  214 
stenosis,  218 
Aphasia,  mixed,  696 

motor,  694 
Apoplectic  habit,  679 
Apoplexy,  679 

chronic,  symptoms,  682 
rigidity  in,  6S2 
serous,  711 
spinal,  718,  719 
symptoms,  681 
treatment,  684 
Appendicitis,  465 
catarrhal,  acute,  465 

prognosis,  472 
chronic,  473 
gangrenous,  471 
prognosis,  472 
peritonitis  in,  47 1 
prognosis,  472 
recurring,  474 
relapsing,  474 
suppurative,  acute,  467 

prognosis,  472 
treatment,  472 
ulcerative.  467 
prognosis,  472 

829 


830 


INDEX. 


Ardent  continued  fever,  S09 
Arj^yll- Robertson  pupil,  709 
Arjtiinioniania,  793 
Arsenical  paralysis,  771 
.Arterial  trunks,  transposition  of,  25 1 
Arteries,  cerebral.     See   Cerebral  ar- 
teries. 
diseases  of,  252 
Arterio-capillary  fibrosis,  193,  206 
Arterio-mesenteric  constriction,  432 
Arterio-sclerosis,  252 

treatment,  255 
Arteritis,  syphilitic,  255 
defonnans,  624 
chronic,  625 
monarticular,  627 
polyarticular,  625 
treatment,  627 
Ascaris  lumbricoides,  821 
Ascites,  507 
adipose,  507 
chylous,  507 
tubercular,  504 
Aseptic  fever,  113 

Asiatic  cholera,  115.     See  also   Chol- 
era. 
Asphyxia,  cholera,  118 

local,  811 
Aspiration-pneumonia,  309 
Asthma,  2S3 

physical  signs,  286 
symptoms,  285 
thymic,  265 
treatment,  287 
Ataxia,  hereditary,  742 
locomotor,  735 
bladder  in,  738 
Charcot's  joints  in,  740 
diagnosis,  differential,  740 

gait.  739 

loss  of  knee-jerk  in,  737 
ocular  symptoms,  738 
pain  in,  737 
paralytic  stage,  741 
rectum  in,  738 
symptoms,  737-740 
treatment,  741 
trophic  changes,  740 
visceral  crises,  740 
Atheroma,  205,  206,  253 
Athetosis,  705 
Atony,  407 

treatment,  409 
Atresia  of  conus  arteriosus,  251 

of  pulmonary-  orifice,  251 
Atrophy,  brown,  233 

cerebral,  in  children,  704 

treatment,  707 
cirrhotic,  400,  402 
idiopathic  muscular,  817 
progressive  muscular,  727 


Atrophy,  progressive  muscular,  treat- 
ment, 730 
unilateral  facial,  S13 
Auditory  area,  693 
nerve,  diseases  of,  757 
speech-centre,  694 
vfertigo,  758 
Aui-ae,  779 

Baccelli's  sign,  365 
Bacillus,  conmia,  116 

of  cerebrospinal  fever,  87 

of  diphtheria,  94 

of  influenza,  81 

of  Koch,  116 

of  small-pox,  51 

of  syphilis,  124 

of  whooping-cough,  78 

parotidis,  76 

tuberculosis,  332 

typhosus,  18 
Basic  ganglia,  697 
Bellows  murmur,  198 
Bell's  mania,  7S6 

palsy,     754.      See    also   Paralysis, 
facial. 
Beri-beri,  771 
Bilharzia  hrematobia,  821 
Biliary  calculi,  543.     See  also  Chole- 
lithiasis. 

cirrhosis,  522 

passages,  inflammation  of,  in  chole- 
lithiasis, 548 
Birth-palsy,  706 
Black  measles,  73 

vomit,  122 
Bladder,  hemorrhage  from,  564 
Blindness,  soul-,  702 

word-,  695 
Blood,  diseases  of,  647 

in  tvphoid  fever,  30 
Bloodlfluke,  821 

Blood-vessels,      spinal,      anaemia     of, 
719 
diseases  of,  719 
hyperajmia  of,  719 
Blue  babies,  252 
Bone-marrow  in  leuksemia,  658 
Bones  of  cranium,  syphilis  of,  711 
Bothriocephalus  latus,  827 
Bovine  heart,  215 
Brachycardia,  241 
Bradycardia,  241 
Brain  abscess,  607 
treatment,  699 

ansemia  of,  679 

blood-vessels  of,  diseases  of,  678 

cancer  of,  700 

congestion  of,  678 

cysts  of,  700 

gummata  of,  700,  712 


INDEX. 


831 


Brain,  hemorrhage  from,  679.    See  also 
Apoplexy. 

hyperajmia  of,  678 

in  cereliro-spinal  fever,  87 

membranes  of,  diseases  of,  668 

oedema  of,  679 

psammoma  of,  700 

sarcoma  of,  700,  713 

sypliilis  of,  71 1 

treatment,  713 

syphilitic  disease  of,  713 

tuljercle  of,  699 

tumors  of,  699 
symptoms,  701 
syphilitic,  700 
treatment,  704 

venous  congestion  of,  acute,  191 
chronic,  192 

wet,  192,  679 
Brain-compression,  symptoms,  672 
Brain-irritation,  symptoms,  671 
Brain-substance,  diseases  of,  692 
Brand's  treatment  of  typhoid  fever,  39 
Bread-and-butter  pericardium,  170 
Bright's  disease,  chronic,  579 
Brodie's  joint,  805 
Bronchi,  diseases  of,  274 
Bronchial  fluke,  821 

glands,  tuberculosis  of,  667 
Bronchiectasis,  281 

cylindrical  form,  2S2 

sacculated  form,  282 
Bronchiolitis  exudativa,  284 
Bronchitis,  acute  catarrhal,  274 
diagnosis,  276 
treatment,  276 
croupous,  278 

capillary,  276,  310 

chronic  catarrhal,  279 
croupous,  281 

diphtheric,  278 

fetid,  279 

in  broncho-pneumonia,  309 

in  children,  275 

in  old  people,  276 

primary,  274 

secondary,  274 
Broncho-pneumonia,  309 

asphyxia  in,  313 

cerebral  cases,  312 

in  adults,  315 

symptoms,  31 1 

terminations,  313 

tubercular,  346 
Broncho-pulmonary  hemorrhage,  290 
Bronchorrhoea,  779 
Brood-capsules,  534 
Brown  atrophy,  233 

induration,  192,  288 
Brown-Sequard's  paralysis,  75^ 
Bruit  de  diable,  648 


Tjubonic  plague,  167 
Bulbar  paralysis,  731 
Bulimia,  437 
Buttonhole  mitral,  210 

Cachexia,  malarial,  145 

strumipriva,  814 
Caecum,  fecal  impaction  in,  490 
Caisson-disease,  720 
Calculi,  dendritic,  601 
renal,  600 

treatment,  604 
Cancer  of  pericardium,  180 
Caput  coli,  cancer  of,  481 

medusfe,  519 
Cardiac    branches    of    pneumogastric, 

761 
Carphologia,  29 
Carpopedal  spasms,  265 
Catarrh,  acute  gastric,  395 
chronic  gastric,  399 
dry,  279 
Cat's  purr  thrill,  212 
Centrum  ovale,  696 
Cerebellum,  697 
tumors  of,  703 
Cerebral  arteries,  aneurysm  of,  687 
embolism  of,  684 
diagnosis,  686 
treatment,  687 
thrombosis  of,  687 
atrophy  in  children,  704 

treatment,  707 
complication  in  rheumatism,  61 1 
endocarditis,  690 
localization,  692 
softening,  684 
Cerebro- spinal  fever,  abortive  cases,  91 
bacillus  of,  87 
brain  in,  87 

Cheyne-Stokes  respiration  in,  90 
early  stages,  89 
hydrocephalic  cry  in,  89 
in  babies,  91 
intermittent,  91 
Kernig's  sign  in,  89 
latter  stages,  90 
lumbar  puncture  in,  90 
malignant  form,  91 
mild  form,  91 
onset,  SS 
treatment,  92 
urine  in,  89 
meningitis,   epidemic,  87.    See   also 
Cerebrospinal  fever. 
Cestodes,  826 
Chalicosis,  318 
Chancre,  hard,  125 
Charcot's  joints,  740 
Cheyne-Stokes  respiration  in  cerebro- 
spinal fever,  90 


8^2 


INDEX. 


Chicken-pov,  60.     See  also  Varicella. 
Chlorosis,   650 

Egyptian,  S23 
Choliemia.  541 
.Cholangitis,  catarrhal,  54S 

suppurative,  54S 
Cholecystitis,  suppurative,  547 
Cholelithiasis,  54J 

iliagnosis,  546 

jierforation  in.  54S 

prophylaxis,  55° 

symptoms,  545 

treatment,  549 
Cholera,  115 

algid  stage  in,  118 

asphyxia,  118 

bacillus  of,  1 16 

collapse  in,  1 18 

complications  and  sequelw,  I18 

infantum,  453 

hydrocephaloid  symptoms,  454 
in  meat-feti  children,  456 
symptoms,  453 
treatment,  455 

moriius,  456 

preliminary  diarrhcea  in,  117 

prophylaxis,  119 

purging  stage,  II7 

reactionary  stage,  1 18 

rice-water  stools  in,  1 17 

sicca,  117 

tepid  stage,  1 18 

treatment,  i  iq 
medical,  120 

typhoid,  119 

warm  stage,  1 18 
Cliolerine,  1 19 
Cholesteraemia,  54I 
Choked  disk,  "OI 
Chorea,  7S7 

chronic,  793 

diagnosis,  791 

electric,  793 

habit-,  793 

Huntingdon's,  793 

hysterical,  803 

in  rheumatism,  61 1 

insaniens,  789 

paralytic,  790 

post-hemiijlegic,  682,  705 

rhythmic,  803 

spastica,  706 

symptoms,  789 

treatment,  792 
Choreiform  affections,  793 
Chyluria,  570 

Cicatrization  in  tyi)lioid  fever,  21 
Circulatory  system,  diseases  of,  169 
Cirrho-^is  ventriculi,  400 
Clavus  hystericus,  803 
Cloudy  swelling,  231 


Coagulation-necrosis,  335 

in  diphtheria,  95 
Coal-gas  neuritis,  771 
Coccygodynia,  775 
Colitis,  457 

amcebic,  459 
treatment,  463 

catarrlial,  acute,  458 
treatment,  463 

chronic,  463 

croupous,  acute,  461 
treatment,  463 

follicular,  452 

mucous,  44S 

renal,  602 

treatment,  605 

treatment,  462 

tropical,  459 
treatment,  463 
Collar  of  flesh,  258 
Collateral  cedema,  289 
Colles'  law,  131 
Coloptosis,  231 
Coma,  diabetic,  631 

vigil,  46 
Comma  bacillus,  1 16 
Compensation,  185 
Compression-myelitis,  749 
Condylomata,  flat,  127 
Congestion  of  lungs,  288 

of  lymph-follicles  in  typhoid,  20 
Conjugate  deviation,  681 
Constitutional  diseases,  607 
Consumption,  344 
Continued  fever,  ardent,  809 
Contusion-pneumonia,  294 
Conus  arteriosus,  atresia  of,  25 1 

stenosis  of,  251 
Convulsions  in  hysteria,  800 

infantile,  776 
treatment,  778 
Coprolalia,  793 
Cor  adiposum,  231 

bovinum,  215 

villosum,  170 
Corona  venerea,  127 
Corpora  amylacea,  744 

quadrigemia,  697 
tumors  of,  703 
Corrigan  pulse,  217 
Cortical  areas,  692 
Coup  de  Soleil,  S08 
Cracked-pot  sound  in  lobar  pneumonia, 

303.  304 
in  pneumonia,  320 
Cranial  nerves,  diseases  of,  751 
Craniotai;es,  640 
in  syphilis,  132 
Cranium,  bones  of,  syphilis  of,  711 

in  rickets,  640 
Cretinism,  813 


INDEX. 


833 


Croup,  catarrhal,  268 

memijranous,  270 

spasmodic,  266 
Crus,  tumors  of,  703 
Ciuschmann's  spirals,  285 
Cutaneous    complications  of    rheuma- 
tism, 6ii 
Cysticerci,  826 
Cystitis,  567 

Dead  fingers  and  toes,  811 
Deafness,  nervous,  758 

word-,  694 
Degeneration  reaction,  724 
Deglutition-pneumonia,  309 

ni  diphtheria,  99 
Deiter's  spider-cells,  744 
Delirium,  acute,  786 

tremens,  810 
Dengue,  treatment,  87 
Diab^te,  bronze,  523,  629 
Diabetes  insipidus,  634 

mellitus,  627 
diet,  632 
pathology,  628 
symptoms,  629 
treatment,  632 

phosphatic,  630 
Diabetic  centre,  628 

coma,  631 

tabes,  632 
Diarrhoea,  442.     See  also  Enteritis, 

acute  dyspeptic,  451 

lienteric,  444 

morning,  442 
Diarrhceal  diseases  of  children,  450 
Diastolic  collapse  in  pericarditis,  179 
Digestive  system,  diseases  of,  3S8 
Dilatation  of  heart,  182,  189 
idiopathic,  190 
physical  signs,  194 
Diphtheria,  93 

antitoxine,  104 

bacillus  of,  94 

coagulation-necrosis  in,  95 

complications  and  sequelae,  lOO 

deglutition-pneumonia  in,  99 

eruption  in,  97 

fever  in,  96 

immunity  from,  94 

incubation  of,  96 

laryngeal,  98 
treatment,  103 

mucous  membranes  in,  94 

nasal,  98 

nose  irrigation  in,  103 

paralysis  in,  100 

pharyngeal,  98 

prophylaxis,  loi 

prostration  in,  96 

serum-therapy,  104 

53 


Diphtheria,  symptoms,  96 
tliroat  irrigation  in,  102 
tonsillar,  97 
treatment,  loi 
Diplegia,  spastic,  706 
Diplococcus  pneunionix',  294 
Distoma  endemicum,  82I 
hepaticum,  821 
lanceolatum,  821 
perniciosuni,  821 
Ringeri,  821 
Diver's  paralysis,  720 
Drinking-water,    typhoid    bacillus    in, 

18,  19 
Dropsy,  abdominal,  507 

of  pericardium,  181 
Duchenne's  paralysis,  726 
Ductus  arteriosus,  persistence  of,  251 
Duodenum,  cancer  of,  482 
round  ulcer  of,  474 
ulceration  of,  475 
Dura  mater  and  pia  mater,  hemorrhage 
between,  677 
and  skull  bones,  hemorrhage  be- 
tween, 676 
diseases  of,  668,  714 
brematoma  of,  669,  714 
perforating  tumors  of,  700 
Dyspepsia,'  chronic,  399 
Dysentery,  457.     See  also  Colitis. 
acute  follicular,  458 
of  children,  452 
Dystrophy,  progressive  muscular,  817 

Eberth's  bacillus,  18 
Echinococcus,  534 
Echolalia,  793 
Echymoses,  641 
Eclampsia,  infantile,  776 

treatment,  778 
Ectopia  cordis,  251 

Ehrlich's  reaction  with   urine   in  ty- 
phoid, 29 
Embolism,  spinal,  720 
Embryocardia,  194,  228 
Emphysema,  compensatory,  32I 
interlobular,  321 
substantive,  322 
vesicular,  321 

physical  signs,  324 
treatment,  325 
variations  in,  324 
Empyema,  370 

liver  abscess  and,  529 
necessitatis,  371 
treatment,  373 
Encephalitis,  suppurative,  697 

treatment,  699 
Endarteritis,  obliterating,  255 

syphilitic,  712 
Endocarditis,  acute,  196 


834 


INDEX. 


Enilocardilis,  acute,  physical  signs,  19S 
syinplonis,  I97 
trcalineiit,  1 99 
cerebral,  690 

treatment,  692 
chronic,  204 

treatment,  222 
effects  of  lesion,  197 
in  lobar  pneumonia,  305 
in  rheumatism,  610 
malignant,  200 
diagnosis,  203 
lesion  of,  201 
symptoms,  202 
treatment,  204 
obliterating,  690 
Endocyst,  534 
Enteric   fever,  17.     See  also  Typhoid 

fcz'er. 
Enteritis,  catarrhal,  acute,  443 
chronic,  445 
diphtheritic,  448 
follicular,  452 
in  typhoid  fever,  22,  26 

treatment,  41 
membranous,  449 
phlegmonous,  447 
pseudo-membranous,  448 
Enteroclysis,  120 
Entero-colitis,^  acute,  451 
Enteroptosis,  431,  560,  800 
Enterorrhagia,  487 

Epidemic  ceiebro-spinal  meningitis, 87 
See  also  Cerebro-spinal  fciier. 
parotitis,  76 
Epilepsy,  778 

cortical,  779,  781 
hystero-,  801 

Jacksonian,  692,  702,  779,  781 
masked,  781 
nocturnal,  781 
procursive,  779 
symptoms,  779 
Epileptic  automatism,  781 
Epithelioid  cells,  335 
Epithelioma  of  stomach,  425 
Erb's  juvenile  muscular  paralysis,  819 
Eructation,  nervous,  442 
Erysipelas,  106 
bacillus  of,  107 
idiopathic,  107 
metastatic,  109 
migrans,  109 
prophylaxis.  109 
traumatic,  107 
treatment,  109 
typhoid  condition  in,  108 
Esbach's  test  for  albumin  in  urine,  563 
Exophthalmic  goitre,  246 

treatment,  249 
Exophthalmos,  247 


Facial  nerve,  diseases  of,  754 

spasm  of,  757 
Farcy,  162 
Farcy-buds,  163 
Fatty  heart,  231 
Fecal  accumulation,  489 

impaction,  490.  491 
Fermentation  fever,  113 
Festinating  gout,  785 
Fibroid  pluiiisis,  343 
Fibro-serous  membranes,  inflammation 

of,  in  rheumatism,  60S 
Fifth  nerve,  diseases  of,  753 
Filaria  sanguinis  hominis,  825 
Floating  kidney,  559 
Foramen  ovale,  patency  of,  250 
Fourlli  nerve,  diseases  of,  753 
Friction  rale  in  pericarditis,  173 
Friedreich's  ataxia,  742 

sign,  179 
Frontal  lobes,  tumors  of,  702 
Fungus  hasmatodes,  700 
Funnel-shaped  mitral,  210 

Gait,  festinating.  785 
in  tabes  dorsalis,  739 
spastic,  734 
Gall-bladder,  dropsy  of,  547 
empysema  of,  547 
retention  of  spores  in,  549 
Gall-ducts,  cancer  of,  551 
Gall-sand,  544 

Gall-stones,  543.  See  also  Cholelithiasis. 
impaction  in  duct,  547 
passage  of,  545 
retention  in  bladder,  549 
Ganglia,  basic,  697 
tumors  of,  703 
Gangrene,  local,  811 

symmetrical,  81 1 
Garland's  S-curve,  363,  365 
Gastralgia,  437 
Gastrectasis,  411 
Gastritis,  acute  catarrhal,  395 
cnju]:)Ous,  398 
sujipurative,  398 
atroj)hic,  401 

gastric  analysis,  404 
symptoms,  403 
catarrhal,  chronic,  399 
gastric  analysis,  403 
prognosis.  404 
sym]3toms,  401 
treatment.  404 
diphtheritic,  398 
from  ptomaine-poisoning,  396 
mycotic,  399 
parasitic,  399 
sclerosing,  400 

gastric  analysis,  404 
symptoms,  401 


INDEX. 


835 


Gastritis,  simple,  400 

gastric  analysis,  403 
symptoms,  401 

toxic,  397 
Gastro-duodenitis,  542 
Gastrodynia,  437 
Gastroptosis,  431 
Gastrorrhagia,  433 
Gastrosuccorrhoea,  440 
Ciastroxynsis,  Rossbach's,  440 
Gilles  de  la  Tourette's  disease,  793 
Girdle  sensation,  744 

ulcers,  477 
Glanders,  162 

acute,  163 

chronic,  164 

swelling  in  pseudo-leuksemia,  662 
Glioma,  699 

Globus  hystericus,  760,  801 
Glosso-pharyngeal  nerve,    diseases   of, 

759 
Glottis  in  typhoid  fever,  22 

oedema  of,  273 
Glycosuria,  510,  570,  627,  633 
Gout,  617 

abarticular,  621 
treatment,  623 

acute,  symptoms,  619 

American,  569 

cardiac,  620 

cerebral,  620 

chronic,  symptoms,  620 
treatment,  623 

gastro-intestinal,  620 

irregular,  621 
treatment,  623 

metastatic,  620 

rheumatic,  624 

suppressed,  620 

symptoms,  619 

testicular,  620 

theories  of,  617 

treatment,  622 

vesical,  620 
Gouty  kidney,  619 

neurosis,  618 
Graefe's  symptom,  247 
Grand  mal,  779 
Graves's  disease,  246 

treatment,  249 
Gray  hepatization,  296 

softening,  743 
Grififin-claw,  729 

Guaiacum  best  for  blood  in  urine,  564 
Gummata,  128 

in  myocardium,  230 

Habit-spasm,  793 
Htfimatemesis,  433 

and  haemoptysis,  differentiation,  436 

in  peptic  ulcer,  423 


Haematomyclia,  719 
IIa;malorrhachis,  718 
Httmaturia,  564 

endemic,  821 
Haimoglobinuria,  565 
lia-mopericardium,  181 
Ha;mophilia,  645 
Haemoptysis,  290 

and  ha-matemesis,  differentiation, 436 

arthritic,  291 
Htemothorax,  382 
Headache  in  influenza,  82 
Head-tetanus,  158 
Heart,  aneurysm  of,  236 

bovine,  215 

causes  preventing  work  of,  182 

congenital  malformations  of,  250 

dilatation    of,    182,    1 89.      See   also 
Dilatation. 

disease,  pneumonia  and,  288 

diseases  of,  182 

error  in  valves  of,  184 

failure  in  lobar  pneumonia,  305 

fatty,  231 

hypertrophy  of,  182,  186.     See  also 
Hypertrophy. 

increased  peripheral  resistanceof,  183 
intermittent  action  of,  239 

lung,  210 

neuroses  of,  238 

palpitation  of,  238 

relative  incompetence  of,  184,  185 

rupture  of,  237 

weakness  of  muscle  of,  182 
Heart-huiTv,  240 
Heart-muscle  in  typhoid  fever,  22 
Heat-and-nitric-acid  test    for    albumin 

in  urine,  563 
Heat-exhaustion,  80S 
Heat-stroke,  808 
Heberden's  nodes,  625 
Heller's  test  for  albumin  in  urine,  563 

for  blood  in  urine,  564 
Hemianopsia,  752 

homonymous,  693 
Hemiatrophy,  facial,  813 
Hemicrania,  795 
Hemiplegia,  infantile,  705 
Hemorrhage,  broncho-pulmonary,  290 

extra-meningeal,  718 

in  typhoid  fever,  26 
treatment,  42 

intra-meningeal,  718 

pulmonary,  290 
Hemorrhagic  infarct,  293 
Henoch's  disease,  644 

treatment,  645 
Hepatic  artery,  aneun-sm  of,  551 

fever,  intermittent,  546 

with  gall-stones,  liver  abscess  and, 
529 


836 


IXDEX. 


Hepatic  vein,  diseases  of,  551 
Hepatitis,  acute  parenchymatous,  515 
chronic  interstitial,  517 
suppurative,  525 
diagnosis,  529 
p"hysical  examination,  528 
symptoms,  5:16 
treatment,  530 
syphilitic,  tlifVuse,  524 
Hepatization,  gray,  296 
red,  295 
white,  329 
Hernia,  internal,  482 

diagnosis,  4S6 
Hippocratic  succussion,  380 
Hodgkin's    disease,    660.       See    also 

Psc^itcio  -  UukiCin  ia . 
Huebner's  arteries,  712 
Huntingdon's  chorea,  793 
Hutchinson  teeth,  133 
Hydatid  fremitus,  536 
Hydrocephalic  cry,  S9,  672 
Hydrocephalus,  acquired  chronic,  711 
acute,  671 
chronic,  710 
congenital,  710 
treatment,  711 
Hydronephrosis,  599 
Hydropericardium,  iSl 
Hydroperitoneum,  507 
Hydrophobia,  153 
Hydro-pneumothorax,  377 

treatment,  381 
Hydrops  vesicce  fellese,  547 
Hydrotherapy  in  typhoid  fever,  39 
Hydrothorax,  382 
Hyperacidity,  439 
Hyperemia,  spinal,  719 
Hyperesthesia,  gastric,  438 

in  hysteria,  803 
Hyperosmia,  751 
Hyperplasia  in  typhoid  fever,  20 
Hyperpyrexia  in  rheumatism,  610 
Hypersecretion,  continual,  440 

periodic,  440 
Hypertrophy  of  heart,  182,  186 
left  side,  187 
right  side,  189 
symptoms,  1 87 
Hypoglossal  nerve,  diseases  of,  764 
Hysteria,  800 

special  senses  in,  803 
symptoms,  801 
circulatory,  805 
digestive,  804 
joint,  805 
mental,  806 
motor,  801 
res]iiratory,  S04 
seniiorv,  803 
urinary,  805 


Hysteria,  temperature  in,  805 

treatment,  S06 
Hysterical  fever,  S05 
Hyslero-epilepsy,  Soi 
Hysterogenic  points,  S03 

Icterus,  539.     See  also  Jaundice. 
Incompetency,  mitral,  207,  251 
of  tricuspid  valve,  252 
relative,  214 
Indicanuria,  570 
Indigestion,  acute,  395 
Infantile  cc.)nvulsions,  776 
treatment,  77S 
remittent  fever,  2,2, 
Infarct,  hemorrhagic,  293 

renal,  600 
Inflammation   of    muscles    in    scarlet 
fever,  68 
of    serous    membranes    in    scarlet 
fever,  68 
Influenza,  Si 
bacillus  of,  81 
convalescence,  84 
headache  in,  82 
pneumonia  in,  83 
symptoms,  82 
treatment,  84 
Inhalation-pneumonia,  309 
Insolation,  S08 
Intellectual  area,  696 
Internal  capsule,  697 
Intestinal  branches  of  pneumogastric, 
762 
lymphoid  tissue  in  typhoid,  20 
obstruction,  482 
diagnosis,  485 
symptoms,  484 
treatment,  486 
Intestines,  acute  venous  congestion  in, 
191 
amyloid  degeneration  of,  492 
cancer  of,  479 

chronic  venous  congestion  in,  192 
diseases  of,  442 
hemorrhage  from,  487 
tumors  of,  non-cancerous,  482 
ulcerations  of,  474 
symptoms,  477 
treatment,  479 
Intoxication,  septic,  II3 
Intussusception,  483 

diagnosis,  485 
Invagination,  4S3 

Jacksonian  epilepsy,  692,  702,  779, 

781 
Jaundice,  539 

acute  febrile,  167 

catarrhal,  542 

hsematogenous,  539,  54O)  54^ 


INDEX. 


«37 


Jaundice,  hepatogenous,  539,  540 

in  yellow  fever,  1 23 

malignant,  515 

non-obstructive,  539,  540,  541 

obstructive,  539,  540 

pernicious,  541 
Jenner  stain  for  blood  in  malaria,  148 

Kak-ke,  771 
Kernig's  sign,  89 
Kidney,  abscesses  of,  593 

acute  venous  congestion  in,  192 

amyloid,  589 

carcinoma  of,  595 

chronic  venous  congestion  in,  193 

congenital  malformations  of,  559 

congestion  of,  acute,  571 

chronic,  571 
cysts  of,  597 

degeneration  of,  acute,  572 
chronic,  573 
hi  scarlet  fever,  66 
waxy,  589 
diseases  of,  559 
fatty,  573 
gouty,  619 
in  scarlet  fever,  66 
in  typhoid  fever,  22 
large  vi'hite,  580 
movable,  559 
pelvis  of,  calculi  in,  603 
sarcoma  of,  595 
small  white,  580 
suppurative  disease  of,  592 

treatment,  594 
surgical,  592 

treatment,  594 
tubercular  diseases  of,  59O 
tuberculosis  of,  590 
tumors  of,  595 
diagnosis,  596 
treatment,  597 
Klebs-Loeffler  antitoxine,  105 
Koch's  bacillus,  1 16 
Koplik's  spots,  71 
Kyphosis,  rachitic,  639 

La  Grippe.     See  also  Influenza. 
Labyrinthine  vertigo,  758 
Lactic-acid  theory  of  rheumatism,  607 
Landouzy-Dejerine  paralysis,  818 
Landry's  paralysis,  747 
Large  white  kidney,  580 
Laryngeal  branches  of  pneumogastric, 
760 

diphtheria,  98 
treatment,  103 
Laryngismus  stridulus,  265 
Laryngitis,  acute  catarrhal,  267 

chronic  catarrhal,  269 

membranous,  270 


Laryngitis,  oedematous,  273 
sijasmodic,  266 
syphilitic,  272 
tubercular,  271 
Larynx,  diseases  of,  265 
in  typhoid  fever,  22 
spasm  of,  265 
tuberculosis  of,  271 
Lead-paralysis,  770 
Leontiasis,  161 
Leprosy,  160 
anaesthetic,  161 
leontiasis  in,  161 
macular,  161 
treatment,  162 
tubercular,  1 61 
white,  181 
Leptomeningitis,  670.  See  also  Menin- 
gitis. 
Leucocythaemia,      656.         See      also 

Leukceniia. 
Leucocytosis,  655 
Leucorrhoea,  567 
Leukemia,  656 
diagnosis,  659 
leucocytes  in,  657 
lymphatic,  658,  659 
symptoms,  658 
treatment,  660 
Lipuria,  570 
Lithcemia,  568 
Liver  abscess,  525 
diagnosis,  529 
physical  examination,  528 
symptoms,  526 
treatment,  530 
acute  nervous  congestion  in,  191 

yellow  atrophy   of,  515 
adenoma  of,  530 
amyloid,  538 
ansemia  of,  512 

blood-vessels  of,  diseases  of,  551 
cancer  of,  531 
symptoms,  532 
with  cirrhosis,  533 
capsule,  diseases  of,  513 
cavernous  angioma  of,  530 
chronic  venous  congestion  in,  193 
circulatory  disturbances  of,  512 
cirrhosis  of,  517 
atrophic,  517 
symptoms,  519 
treatment,  521 
f-itty,  523 
hypertrophic,  522 

with  jaundice,  522 
syphilitic,  523 
congestion  of,  512 
diseases  of,  510 
echinococcus  cyst  of,  534 
fatty,  536 


8;S 


INDEX. 


Liver,  fatty,  treatment,  53S 
function,  disturbances  of,  510 
gunimata  of,  524 
hytlatid.  534 

treatment.  536 
in  typlioiii  fever,  22 
lardaceous,  53S 
leul<a-mic  deposits  m,  530 
new  growths  of.  530 

treatment,  533 
nutmeg,  193,  512 
sarcoma  of,  530 
tubercular  disease  of,  530 
waxy,  538 
Liver-Huke,  821 
Living  skeletons,  730 
Lobar  pneumonia,  294.    See  also  Pneu- 
monia. 
Localization,  cerebral,  692 
cortical,  692 
subcortical,  696 
Lock-jaw,  156,  753.   See  also  Tetanus. 
Locomotor    ataxia,    735.       See     also 

Ataxia. 
Lumbago,  616 
Lumbar    puncture    in    cerebro-spinal 

fever,  90 
Lung  heart,  210 
Lungs,  abscess  of,  328 

in  lobar  pneumonia,  304 
acute  venous  congestion  of,  191 
carcinoma  of,  330 
chronic  venous  congestion  of,  J 92 
circulatory  disturbances  of,  288 
congestion  of,  288 
diseases  of,  28S 
echinococcus  cysts  of,  332 
gangrene  of,  326 

in  lobar  pneumonia,  305 
gummata  in,  330 
hemorrhage  into,  290    . 
in  typhoid  fever,  23 
new  growths  in,  330 
cedema  of,  289 

in  lobar  pneumonia,  305 
sarcoma  of,  331 
syphilis  of,  329 

tubercular  diseases  of,  332,  336 
tuberculosis  of,  332 
acquired,  11^, 

conditions  favoring  infection,  333 
healing  of  nodules,  336 
hereditary,  t^t,-^ 
secondary  inflammatory  processes, 

symptoms,  336 
Lustgarten's  bacillus,  124 
Lymphadenitis,  383 

tuberculous,  667 
Lymphatic  glands,  diseases  of,  647 

tuberculosis  of,  666 


Lymphalic  glands  in  leukemia,  658 
Lymph-follicles  in  typhoid  fever,  20 

Main  de  grifle.  729 
^Lllaria,  1 38 

ajslivo-autumnal,  140 
ague-cake  in,  143,  147 
blood-examination  in,  I47 
cachexins  in,  145 
conditions  favoring,  14I 
continuous,  145 
crescents  in  blood  in,  140 
diagnosis,  146 

extracorpuscular    pigmented    organ- 
isms in,    140 
flagellate  bodies  in  blood  in,  139 
hajmosporidia  of,  138 

flagellate  form,  139 

hyaline  form,  139 

pigmented  form,  139 

segmenting  form,  139 
in  typhoid  fever,  35 
intermittent,  143 
irregular  forms,  144 

intermittent,  145 
liver  abscess  and,  529 
mosquitoes  and,  14 1 
ovoids  in  blood  in,  140 
pathology,  142 
pernicious,  145 

algid  form,  145 

comatose  form,  145 

gastro-enteric  form,  145 

hemorrhagic  form.  145 
pigmented  leucocytes  in  blood  in,  139 
prognosis,  148 
prophylaxis,  149 
fjuartan,  140.  144 
quinine  for,  150 
regular  forms,  143  • 
remittent,  145 
sources  of  infection,  I4I 
symptoms,  143 
tertian,  140,  143 
treatment,  150 
typho-,  146 
Malignant  redema,  152 

pustule,  152 
Mania,  epile])tic,  781 

in  acute  miliary  tuberculosis,  137 
McIJurney's  jioint,  466 
Measles,  70 
black;  73 
eruption  of,  72 
German,  74 
hemorrhagic,  73 
Koplik's  spots  in,  71 
respiratory  complications  in,  73 
treatment,  73 
Mediastinum,  abscess  of,  386 
diseases  of,  383 


INDEX. 


839 


Mediastinum,  emphysema  of,  386 

hemorrliage  into,  3S7 

tumors  of,  384 
Medulla,  tumors  of,  703 
Melrena  neonatorum,  435,488 
Melanin,  139 
Meniere's  disease,  758 
Meningeal  hemorrhage,  676 

of  new-born,  677 
Meninges,  affections  of,  714 
Meningitis,  acute,  715 

basilar,  671 

cellular,  673 

chronic,  675,  7 '7 

epidemic    cerebro-spinal,    87.     See 
also  Cerebro-spinal  fever. 

exudative,  673 

in  lobar  pneumonia,  305 

non-tubercular,  acute,  673 
treatment,  675 

syphilitic,    712.       See    also    Brain, 
syphilis  of. 

tubercular,  670 

and      non-tubercular,    differentia- 
tion, 674 
treatment,  673 
Merycismus,  441 

Mesenteric  glands   in   typhoid    fever, 
21 
tuberculosis  of,  667 
Microbic  theory  of  rheumatism,  607 
Migraine,  795 

treatment,  797 
Miliary  tubercles,  341 

tuberculosis,   acute,   133.     See   also 
Tuberculosis,  acute  miliary. 
Milk  sickness,  166 
Mitral  incompetency,  207,  251 

stenosis,  210,  251 
Morbus  cEeruleus,  252 

coxa;  senilis,  627 

maculosus,  642 
treatment,  645 
Morphoea,  815 
Mosquitoes  and  malaria,  14I 
Motor  aphasia,  694 

area,  692 

tumors  of,  702 

speech-centre,  694 
Movable  kidney,  559 
Mulberry  calculus,  601 

rash,  46 
Mumps,  76 

orchitis  in,  77 
Muscles,  diseases  of,  S17 
Mycosis  intestinalis,  153 
Myelitis,  743 

acute,  743 

chronic,  743,  744 

compression-,  749 

disseminated,  744 


Myelitis,  general,  744 
symptoms,  744 
transverse,  744 
treatment,  746 
Myocarditis,  acute,  227 
circumscribed,  227 
diffuse,  227 
suppurative,  227 
chronic,  228 
in  rheumatism,  610 
syphilitic,  230 
Myocardium,  degeneration  of,  230 
pathology,  233 
physical  signs,  235 
symptoms,  233 
treatment,  235 
diseases  of,  227 
gumma  in,  230 
Myoclonus  multiplex,  819 
Myosis  spinalis  in  tabes  dorsalis,  738 
Myositis,  817 
Myotonia  congenita,  819 
Myxoedema,  813 
operative,  814 

Nasal  diphtheria,  98 
Nausea  in  typhoid  fever,  25 
Necrosis,  anaemic,  230 
in  typhoid  fever,  21 
Necrosis,  coagulation-,  335 
Nematodes,  821 
Nephritis,  acute  diffuse,  576 
treatment,  578 
exudative,  574 
chronic,  579 

diffuse,  with  exudation,  579 
symptoms,  581 
treatment,  582 
without  exudation,  583 
symptoms,  585 
treatment,  588 
in  scarlet  fever,  67 
scarlatinal,  63 
suppurative,  593 
Nephrolithiasis,  600 

treatment,  604 
Nephroptosis,  431,  559 
Nervo-humoral  theory  of  gout,  618 
Nervous  deafness,  758 
diseases,  general,  776 
system,  diseases  of.  668 
theory  of  gout,  618 
of  rheumatism,  607 
Neuralgia,  773 

cervico-brachial,  774 
cervico-occipital,  774 
inferior  maxillary,  754 
intercostal,  774 
lumbar,  775 
of  fifth  nerve,  753 
superior  maxillary,  754 


S40 


INDEX. 


Neuralgia,  supraorbital,  754 

treatment,  775 
^  triHicial,  773 
Neurasthenia,  798 

diagnosis,  Soo 

litha-qiic,  Soo 

treatment,  Soo 
Neuritis,  705 

alcoholic,  769 

ascending,  767 

coal-gas,  771 

interstitial,  766 

liponiatous,  766 

localized,  765 
symptoms,  767 
treatment,  767 

migrative,  767 

multijile,  76S 
treatment,  772 

optic,  in  brain  tumors,  701 

parenchymatous,  766 

peripheral,  in  diabetes,  632 

post-lebrile,  770 

rheumatic,  766 
Neuro-glioma,  699 
Neuromata,  772 

Neuroses,    gastric,     436.      See     also 
Stomach,    neuroses   of. 

gouty,  618 

occupation-,  797 
Nodules,  rheumatic,  612 
Nurse's  contracture,  794 
Nutmeg  liver,  193,  512 

Occipital  lobe,  tumors  of,  702 
Occupation-neuroses,  797 
CEdema,  acute  circumscribed,  812 

collateral,  289 

malignant,  152 
CEsoph^eal  branches  of  pneumogas- 

tric,  762 
CEsophagismus,  392 
CEsophagitis,  acute,  388 

chronic,  389 
CEsophagus,  dilatations  of,  393 

diseases  of,  38S 

diverticula  of,  393 

paralysis  of,  394 

rupture  of,  394 

stenosis  of.  389 
cancerous,  39I 
cicatricial,  389 
spasmodic,  392 

varix  of,  394 
Olfactory  nerve,  diseases  of,  75 1 
Oligaemia,  647 
Oligochromiumia,  647 
Oligocythemia,  647 
Ophthalmojiiegia,  732 

externa,  732 

interna,  733 


Optic  nerve,  diseases  of,  751 
Orchitis  in  mumps,  77 
Osteoarthropathy,    hypertrophic    pul- 
monary. Si  6 
Osteocopic  pain,  12S 
Oxaluria,  569 
Oxyuris  vermicularis,  S22 

Pachymeningitis,  acute  external,  668 

internal,  668 
chronic  internal,  669 
externa,  714 

chronica,  714 
interna  ha^norrhagica,  714 

hypertro]ihica,  714 
syphilitic,  670 
Palpitation,  238 
Palsy,  birth-,  706 

Paludism,  138.     See  also  Malaria. 
Pancreas,  cancer  of,  557 
cysts  of,  556 
diseases  of,  553 
hemorrhage  into,  553 
new  growths  of,  558 
Pancreatitis,  acute  hemorrhagic,  553 
chronic,  556 
gangrenous,  555 
suppurative,  555 
Paralysis,  abducens,  754 
acute  ascending,  747 
agitans,  784 

diagnosis,  786 

treatment,  786 
arsenical.  771 
atrophic  spinal,  722 
Bell's,    754.     See     also    Paralysis^ 

facial. 
Brown-Sequard's,  751 
bulbar,  731 
diver's,  720 
iJuchenne's,  726 
facial,  754 

middle  form,  757 

mild  form,  756 

severe  form,  757 

symptoms,  755 
glosso-labio-laryngeal,  731 
hypertrophic,  818 
in  diphtheria,  loo 
in  hysteria,  802 
infantile,  722 

muscular,  818 

treatment,  725 
infranuclear,  755 
Landry's,  747 
laryngeal,  760 
lead-,  770 
nuclear,  755 
of  fifth  nerve,  753 
of  fourth  nerve,  753 
of  hypoglossal  nerve,  764 


INDEX 


841 


Paralysis  of  insane,  general,  708 

of  oesophagus,  762 

of  pharyngeal  nerves,  759 

of  spinal  accessory,  763 

peripheral,  755 

primary  atrophic,  818 

pseudo-bulViar,  732 

pseudo-hypertrophic  muscular,   817, 
818 

supranuclear,  754 

syphilitic,  713 
Paramyoclonus  multiplex,  819 
Paramyotonia,  congenital,  820 
Paraphasia,  696 
Paraplegia,  ataxic,  743 

dolorosa,  750 

spastic,  733 
diagnosis,  735 
of  infants,  735 
treatment,  735 
Parasites,  animal,  821 
Parenchymatous  degeneration,  231 
Paresis,  general,  708 

treatment,  710 
Parieto-occipital  lobe,  tumors  of,  702 
Parkinson's  disease,  784 

mask,  7S5 
Parosmia,  751 
Parotitis,  epidemic,  76 
orchitis  in,  77 

in  typhoid  fever,  22 
Pasteur  treatment  for  rabies,  155 
Peliosis  rheumatica,  642 

treatment,  645 
Pemphigus  neonatorum,  132 
Penny- click,  380 
Peptic  ulcer,  416.     See  also  Stomach, 

tilcer  of. 
Peptonuria,  567 
Perforation  in  typhoid  fever,  33 

treatment,  42 
Peri-arteritis,  gummatous,  256 
Pericarditis,  169 

cancerous,  180 

chronic  adhesive,  178 

diagnosis,  175 

friction  rale  in,  173 

heart-action  in,  172 

idiopathic,  169 

in  lobar  pneumonia,  305 

in  rheumatism,  610 

latent,  174 

lesion,  170 

mild,  174 

physical  signs,  1 72 

primary,  169 

prognosis,  176 

purulent,  177 

secondary,  169 

severe,  174 

symptoms,  171 


Pericarditis,  terminations,  171 
treatment,  176 
tubercular,  179 
Pericardium,  bread-and-butter,  170 
diseases  of,  169 
dropsy  of,  18 1 
Perihepatitis,  acute,  513 
chronic  fibrinous,  514 
syphilitic,  515,  523 
Perinephritic  abscess,  606 
Peripheral  nerves,  diseases  of,  765 
Peristaltic  unrest,  441 
Peritoneum,  acute  tuberculosis  of,  502 
venous  congestion  in,  I91 
cancer  of,  505 
carcinosis  of,  505 
chronic  venous  congestion  in,  193 
diseases  of,  492 

tubercular  inflammations  of,  502 
Peritonitis,  acute,  492 
circumscribed,  497 

treatment,  499 
diffuse,  494 
treatment,  498 
adhesive,  500 
ascitic,  500 
cancerous,  505 
chronic,  499 

hemorrhagic,  501 
exudative,  494 

treatment,  498 
idiopathic,  492 
in  appendicitis,  471 
in  typhoid  fever,  22,  33 

treatment,  42 
perforative,  493 
primary,  492 
progressive,  494 
treatment,  498 
proliferative,  500 
purulent,  494 

treatment,  498 
secondary,  492 
treatment,  49S 
tubercular,  acute,  502 
chronic,  504 
with  adhesions,  504 
Perityphlitic  abscess,  468 
Perles,  285 
Pertussis,    78.      See    also    IVJiooping- 

cough. 
Petechia;,  641 
Petit  mal,  779,  781 
Peyer's  glands  in  typhoid  fever,  20 
Pfeiffer  bacillus,  81 
Phantom  tumors,  803 
Pharyngeal    branches   of    pneumogas- 
tric,  759 
diphtheria,  98 
Pharyngitis  in  rheumatism,  6l2 
in  scarlet  fever,  treatment,  69 


842 


IXDEX. 


Phosphaturia,  56S 
Phthisis,  acute  pneumonic,  345 
fibroid,  343 
tlorida,  344 
pulmonaiy,  acute,  344 
chronic,  34S 
synipionis,350 
Pia    mater   and    tkna    mater,    hemor- 
rhage between,  677 
diseases  of,  670,  715 
Picric-acid  test  for   albumin  in  urine, 

563 
Pigeon-breast,  639 
Pigment  induration,  192 
Pin-worm,  S22 
Plague,  bubonic,  167 
Pleura,  acute  venous  congestion  of,  191 
chronic  venous  congestion  of,  192 
diseases  of,  360 
new  growths  of,  38 1 
Pleurisy,  chronic,  374 
dry,  360 
fibrinous,  360 
in  lobar  pneumonia,  304 
in  rheumatism,  610 
plastic,  360 
primary,  360 
purulent,  370 

treatment,  373 
sero-hbrinous,  362 
tubercular,  376 
with  effusion,  362 
sequelse,  36S 
symptoms,  364 
treatment,  368 
Pleurodynia,  616 
Pneumococcus,  294 
Pneumogastric  nerve,  diseases  of,  759 
Pneumonia,  acute  tubercular,  345 
aspiration-,  309 

broncho-,  309.     See   also   Broncho- 
pneumonia. 
central,  303 

chronic  interstitial,  in  lobar  pneumo- 
nia, 306 
contusion-,  294 
croupous,  294.  See  also  Pneumonia, 

lobar. 
deglutition-,  309 
in  influenza,  83 
inhalation-,  309 
interstitial,  318 

treatment,  321 
lobar,  294 

complications,  304 
pathology,  295 
])hysical  signs,  301 
prognosis,  306 
stages,  301 
symptoms,  297 
cerebral,  300 


Pneumonia,  lobar,  symptoms,  digestive, 
301 
toxine  for,  308 
treatment,  306 
of  heart  disease,  192,  288 
pseudo-lobar,  310 
rheumatic,  610 
syphilitic  tibroid,  330 
white,  329 
Pneumonokoniosis,  318 
Pneumothorax,  377 
treatment,  3S1 
ventilating,  378 
Pneumotoxine,  30S 
Pneumopericardium,  1 8-1 
Podagra,  617.     See  also  Gout. 
Poisoning  of  heart-muscle,  232 
Poliomyelitis,  acute  anterior,  722 
anterior,  in  adults,  726 
in  children,  722 
treatment,  725 
chronic,  726 
anterior,  727 
treatment,  730 
subacute,  726 
Polyneuritis,  acute  febrile,  768 
Pons,  tumors  of,  703 
Portal  veins,  obstruction  of,  551 

thrombosis  of,  552 
Post-hemiplegic  chorea,  682 
Potain-Rosenbach  murmur,  210 
Prune-juice  s]iutum,  230 
Pseucio-aiigina,  245 
Pseudo-bulbar  paralysis,  732 
Pseudo-croup,  268 
Pseudo-hydrocephalus,  454 
Pseudo-leukaemia,  660 
diagnosis,  663 
treatment,  664 
Pseudo-rabies,  156 
Pseudo-rheumatism,  614 
Ptomaine-poisoning,  gastritis  from,  396 
Pulmonary  apoplexy,  293 

branches  of  pneumogastric,  761 
hemorrhage,   290 
orifice,  atresia  of,  251 

stenosis  of,  251 
phthisis.      See   Phthisis. 
regurgitation,  221 
stenosis,  222 

tuberculosis.     See  Tuberculosis. 
Pulsus  paradoxus,  172 
Purpura,  fulminating,  642 
hsemorrhagica,  642 
acute,  642 

treatment.  645 
sulincute,  643 

treatment.  645 
treatment.  645 
rheumatica,  642 
treatment,  645 


INDEX. 


843 


Purpura,  symptomatic,  64I 

treatment,  645 
Purpuric  diseases,  640 

treatment,  645 
Pyeemia,  1 11 

arterial,  iii 

diagnosis,  1 12 

idiopathic.  III 

treatment,  113 
Pyelitis,  567,  598 
Pyelonephritis,  567 

suppurative,  593 
from  cystitis,  594 

tubercular,  590 
treatment,  592 
Pylephlebitis,  adhesive,  552 

suppurative,  552 
Pyloric  spasm,  442 
Pyonephrosis,  593 
Pyo-pneumothorax,  377 

subphrenic,  418,  497,  513 

treatment,  381 
Pyuria,  567 

Rabies,  153 

Rachitic  rosary,  639 

Rachitis,  638.     See  also  Rickets. 

Rales,  pleuritic   and   bronchial,  differ 

entiation,  362 
Raynaud's  disease,  811 
Reaction  of  degeneration,  724 
Rectum,  cancer  of,  480 

impaction  in,  491 
Red  hepatization,  295 

softening,  685,  743 
Regurgitation,  aortic,  214 

pulmonary,  221 

tricuspid,  220 
Reichmann's  disease,  440 
Relapsing  fever,  48 
crisis  of,  50 
spirillum  of,  49 
treatment,  51 
Relative  incompetence,  214 
Renal  calculi,  600 
treatment,  604 

colic,  602 

treatment,  605 

hemorrhage,  564 

sand,  601 
Respiratory  system,  diseases  of,  265 
Retroperitoneal     glands,     tuberculosis 

of,  667 
Rheumatic  fever,  607 

treatment,  612 
Rheumatism,  abarticular,  60S 

acute  articular,  607 
treatment,  612 

chronic  articular,  614 

complications,  609 

muscular,  616 


Rheumatism,  scarlatinal,  68 

secondary,  614 

subacute,  609 

theories  of,  607 
Rheumatisme  fibre ux,  615 
Rice-water  stools,  117 
Rickets,  638 

acute,  638 

bones  in,  639 

treatment,  640 
Romberg's  symptom,  739 
Roseola,  74 

Rossbach's  gastroxynsis,  440 
Rotheln,  74 
Rubella,  74 

Rubeola,  70.     See  also  Measles. 
Rumination,  441 
Rusty  sputum,  300 

Sapr^mia,  114 

Sardonic  grin  in  tetanus,  158 

Scarlatina,  61.    See  also  Scarlet  fever. 

Scarlatinal  nephritis,  63 

Scarlet  fever,  61 

angina  from,  66 
desquamation  in,  64 
eruption  of,  63 
fever  in,  treatment,  68 
hemorrhagic  form,  66 
incubation  of,  63 
inflammation  of  muscles  in,  68 
of  serous  membranes  in,  68 
invasion  of,  63 
kidneys  in,  66 
malignant  form,  65 
mild  form,  65 

pharyngitis  in,  treatment,  69 
prolonged  cases,  65 
rudimentary  form,  65 
severe  form,  65 
tongue  in,  64 
treatment,  68 
urine  in,  67 
Schonlein's  disease,  642 

treatment,  645 
Sciatica,  775 
Sclerema,  815 
Scleroderma,  815 

Sclerosis,  amyotrophic  lateral,  728,  730 
cerebro-spinal,  707 
lateral,  733.     See   also   Paraplegia, 
spastic. 
Scolices,  534 
Scoliosis,  rachitic,  639 
Scorbutus,  635 

in  children,  636 
Scrofula,  666 
Scurvy,  635 

in  children,  636 
Sensory  area,  693 
Sepsis,  113.     See  also  Septiccemia. 


844 


INDEX. 


Septa,  defects  of,  250 
Septicivmia,  1 13 

acute  peripheral,  493 

peritoneal,  treatment,  498 

progressive,  114 
Seventh  nerve,  diseases  of,  754 

spasm  of,  757 
Shaking  palsy,  784 
Sick  headache,  795 
Siilerosis,  318 

Sinuses,  venous,  thrombosis  of,  689 
Sixth  nerve,  diseases  of,  754 
Skin,  acute  venous  congestion  in,  192 

chronic  venous  congestion  in,  193 

in  Addison's  disease,  665 
Skoda's  sign,  366 

Skull  bones,  dura  mater  and,   hemor- 
rhage between,  676 
Small  white  kidney,  5S0 
Small-pox,  51 

bacillus  of,  51 

confluent  form,  55 

discrete  form,  52 

eruptive  stage,  53 

hemorrhagic  form,  56 

incubation  period,  52 

invasion  stage,  52 

malignant  form,  56 

pitting  in,  54,  58 

secondary  fever,  55 

treatment,  58 
Smell-centre,  694 
Softening,  cerebral,  684 

red,  685 

white,  685 

yellow,  685 
Sore  throat,  sympathetic,  65 
Soul-blindness,  702 
Southey's  tubes,  226 
Spasm  in  hysteria,  802 

laryngeal,  760 

of  spinal  accessory  nerve,  763 

of  tongue,  765 

pharyngeal,  759 

retrocollic,  764 
Spasmotoxine,  157 
Spastic  gait,  734 
Speech-centres,  694 

auditory,  694 

motor,  694 

visual,  695 

writing,  696 
Spider-cells,  Deiters',  744 
Spinal    accessory   nerve,    diseases    of, 
762 

cord,  diseases  of,  714 
embolism  in,  720 
hemorrhage  into,  719 
slow  compression  of,  749 
substance,  diseases  of,  722 
thrombosis  in,  720 


Spinal  coril,  tumors  of,  750 

membranes,  hemorrhage  into,  718 
Spirill-um  of  relapsing  fever,  49 
Splanchnoptosis,  431 
Spleen,    acute    venous    congestion   in, 
191 
in  leukcemia,  657 
in  typhoid  fever,  22,  29 
Sponiiyiitis  deformans,  627 
Sputum,  prune-juice,  230 

rusty,  300 
St.  Gothartl's  disease,  S23 
St.    Vitus's     dance,    788.       See    also 

Choiea. 
Status  epilepticus,  7S0 
Stcllwag's  symptom,  247 
Stenosis,  aortic,  218 
mitral,  210,  252 
of  aortic  orifice,  251 
of  conus  arteriosus,  251 
of  pulmonary  orifices,  251 
pulmonary,  222 
tricuspid,  221,  251 
Stomach,  acute  venous  congestion  in, 
191 
atrophy  of,  cirrhotic,  400 
cancer  of,  424 

gastric  analysis,  428 
hemorrhages,  427 
pathology,  424 
physical  examination,  429 
symptoms,  426 
treatment,  430 
chronic  venous  congestion  in,  192 
dilatation  of,  411 
gastric  analysis,  413 
treatment,  415 
diseases  of,  395 
hemorrhage  from,  433 

haemoptysis   and,     differentiation, 
436 
mucous  membrane  of,  congestion  in, 

434 
neuroses  of,  436 
motor,  441 
secretory,  439 
sensory,  437 
polypi  of,  431 

secondary  growths  of,  426,  428 
tumors  of,  non -cancerous,  431 
ulcer  of,  416 

pathogenesis,  418 
sequelae  and  complications,  417 
symjitoms,  419 
treatment,  422 
Strangulation,  482 

diagnosis,  486 
Strawberry  tongue,  64 
Streptococcus  of  erysipelas,  107 
Strongylus  duodenal  is,  823 
Stupor,  syphilitic,  712 


INDEX. 


845 


Subacidity,  nervous,  439 

Subcorlical  localization,  696 

Subphrenic  abscess,  513 

Subsultus  tendinum,  29 

Sun-stroke,  807,  808 

Sydenham's   chorea,    788.       See    also 

Chorea. 
Syncope,  local,  811 
Synovitis,  rheumatic,  608 
Syphilides,  late,  127 
Syphilis,  124 
acquired,  125 

amyloid  degeneration  in,  128 
eruption  in,  127 
hard  chancre  in,  125 
iodide  of  potassium  in,  13 1 
mercury  in,  129 
mixed  treatment,  130 
osteocopic  pain  in,  128 
parchment  induration  in,  126 
primary  stage,  125 
prognosis,  128 
prophylaxis,  129 
secondary  stage,  126 
tertiary  stage,  1 27 
treatment,  129 
bacillus  of,  1 24 
extra-genital,  125 
heredity,  1 31 
teeth  in,  133 
treatment,  133 
Syphilitic  stupor,  712 
Syringo-myelia,  748 

Tabes,  diabetic,  632 

dorsalis,    735.      See    also    Ataxia, 
locot?iotor. 

mesenterica,  667 
Tachycardia,  240 
Tseniffi,  826 

mediocanellata,  826 

saginata,  826 

solium,  826 
Tape-worms,  826 
Taste-centre,  694 
Temporal  lobes,  tumors  of,  703 
Tetanilla,  794 
Tetanine,  157 
Tetanotoxine,  157 
Tetanus,  156 

bacillus  of,  156 

differential  diagnosis,  1 59 

heat-,  158 

hydrophobic,  158 

idiopathic,  157 

neonatorum,  157 

sardonic  grin  in,  158 

treatment,    159 
Tetany,  794 
Thermic  fever,  808 
Third  nerve,  diseases  of,  752 


Thomsen's  disease,  819 
Thoracic    aorta,  aneurysm    of,   symp- 
toms, 257 
Thread-worm,  822 
Thrombosis,  spinal,  720 
Thymic  asthma,  265 
Thymus  gland,  aljscess  of,  387 
carcinoma  of,  387 
diseases  of,  387 
hemorrhages  into,  387 
hypertrophy  of,  387 
sarcoma  of,  387 
Tic  convulsif,  757,  774,  793 
douloureux,  753,  773 
simple,  793 
spasmodic,  754 
Tongue  in  scarlet  fever,  64 
in  typhoid  fever,  25 
paralysis  of,  764 
spasm  of,  765 
Tonsillar  diphtheria,  97 
Tonsillitis  in  rheumatism,  612 
Torticollis,  616,  763 

spasmodic,  763 
Trematodes,  821 
Tremor  cordis,  239 
Trichina  spiralis,  823 
Trichocephalus  dispar,  823 
Tricuspid  regurgitation,  220 
stenosis,  221,  251 
valve,  incompetency  of,  251 
Trismus,  753 
Trophic  disorders,  81 1 
Trousseau's  penny-click,  380 

phenomenon,  795 
Tubercle,  diffuse,  335 
miliary,  335,  341 
structure,  334 
Tuberculosis,  acute  miliary,  133 
delirium  type,  137 
diagnosis,  137 
fever  type,  1 21 
inversive  type,  1 34 
mania  in,  137 
meningeal  type,  136 
pulmonary  type,  137 
symptoms,  134-136 
treatment,  137 
arrestment  of,  356 
bacillus  of,  332 
diet  in,  357 
drugs  in,  358 
hygiene  in,  357 
miliary,  341 
of  pericardium,  179 
prophylaxis,  356 
pulmonary,  337 
acute,  337 
chronic,  340 
relief  of  symptoms,  359 
treatment,  356 


846 


INDEX. 


Typhoid,  cliolcra,  1 19 
fever,  17 
aboried,  32 
air-luin'jer  in,  27 
ambulatory,  31 
appetite  in,  25 
bacillus  of,  18 
blood  in,  30 
Brand's  treatment,  39 
complications,  y},,  47 
constipation  in,  42 
convalescence,  36 

treatment,  42 
delirium  in,  28 
diarrho-a  in,  26 

treatment,  4I 
diet  in,  2)^ 

drinking-water  and,  18,  19 
Ehrlich's  urine  reaction  in,  29 
enteritis  in,  22 
eruption  in,  30 
fever  of,  23 

treatment,  39 
first  week,  31 
fourth  week,  32 
gastrointestinal  symptoms,  25 
general  management,  38 
glottis  in,  22 
gurgling  in,  26 
headaclie  in,  27 
heart-nuiscle  in,  22 
hemorrh,age  in,  26 

treatment,  42 
hydrotherajjy  in,  39 
in  aged,  t^}, 
in  children,  t,^, 
incubation  period,  30 
insidious  cases,  32 
internal  antiseptics,  41 
intestinal  antiseptics  in,  39 

lymphoid  tissue  in,  20 
kidneys  in,  22 
larynx  in,  22 
liver  in,  22 
lungs  in,  23 
malaria  in,  35 
mesenteric  glands  in,  21 
modes  of  infection,  19 
mortality,  36 

muscular  prostration  in,  28 
nausea  in,  25 
nervous  symptoms,  27 

treatment,  42 
onset,  30 
pain  in,  26 
parotitis  in,  22 
perforation  in,  T^-i^ 

treatment,  42 
peritonitis  in,  22,  33 

treatment,  42 
pharynx  in,  22,  25 


Typhoid  fever,  prognosis,  36 

prophylaxis,  37 

pulse  in,  25,  41 

recrudescences,  35,  43 

relapses,  35 

second  week,  31 

slush  bath  in,  41 

spleen  in,  22,  29 

symptoms,  23 

tenderness  in.  26 

thinl  week,  32 

tongue  in,  25 

treatment,  37 
medical,  39 

tynijianiies  in,  26,  42 

urine  in,  29,  34 

vomiting  in,  25,  41 

walking  cases,  31 

Widal  reaction  in,  30 
Typho-malaria,  146 
Typhus  fever,  43 

cerebral  symj-itoms,  46 

coma  vigil  in,  46 

eruption  of,  45 

fatal  symptoms,  46 

mulberry  rash  in,  46 

treatment,  47 

Ulceration  in  typhoid,  21 
Ulcus  carcinomatosum,  418 

gastric  analysis,  429 
Umhilicated  appearance  of  liver,  531 
Urjemia,  5S5 

treatment,  589 
Uiremic  amaurosis,  587 
Ureter,  hemorrhage  from,  564 

impaction  of  calculus  in,  602 
treatment,  605 

passage  of  calculus  through,  601 
Urethra,  hemorrhage  from,  564 
Urethritis,  567 
Uric-acid  infarcts,  600 

theory  of  gout,  617 
of  rheumatism,  607 
Uricoemia,  568 

Urinary    passages,  rupture   of  abscess 
into,  567 

secretion,  anomalies  of,  561 
Urine,  acetone  in,  571 

albumin  in,  561 

blood  in,  564 

chyle  in,  570 

fat  in,  570 

in  cerebro-spinal  fever,  89 

in  diabetes  mellitus,  629 

in  hysteria,  805 

in  scarlet  fever,  67 

in  typhoid  fever,  29,  34 

indigo  in,  570 

oxalate  of  lime  in,  569 

peptone  in,  567 


INDEX. 


847 


Urine,  phosphates  in,  568 

pus  in,  567 

sugar  in,  570 
Urticaria,  giant,  812 

Vaccination,  59 
Vaccinia,  59 
Valvular  disease,  204 

treatment,  222 
Varicella,  60 

Variola,  51.     See  also  Small-pox. 
Varioloid,  56 
Varix,  aneurysmal,  256 
Vaso-motor  disorders,  Si  I 
Venous  congestions,  acute,  1 91 
chronic,  192 

sinuses,  thrombosis  of,  689 
Vertigo,  auditory,  758 
Visual  area,  693 

speech-centre,  695 
Volvulus,  484 

diagnosis,  486 
Vomiting,  nervous,  441 

Water-hammer  pulse,  217 
Weil's  disease,  167 
WerlhofF's  disease,  642 

treatment,  645 
Westphal's  symptom,  737 
Wet  brain,  192,  679 


Whip-worm,  823 
While  hepatization,  329 

kidney,  580 

softening,  685 
Whooping-cough,  78 

bacillus  of,  78 

treatment,  80    „ 
Widal  reaction,  30 
Wintrich's  sign,  354 
Wooden  note,  325 
Wool-sorters'  disease,  151,  153 
Word-blindness,  695 
Word-deafness,  694 
Worms,  821 

tape-,  826 
Writers'  cramp,  797 
Writing  speech-centre,  696 
Wry-neck,  616,  763 


Yellow  fever,  121 
bacillus  of,  121 
black  vomit  in,  122 
diagnosis,  1 23 
immunity  from,  121 
jaundice  in,  123 
prophylaxis,  124 
treatment,  124 
typhoid  condition  in,  123 
softening,  685 


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Medical  College,  Chicago;  and  David  Ries.man,  M.  D.,  Demonstrator 
of  Pathologic  Histology  in  the  University  of  Pennsylvania.  Handsome 
imperial  octavo,  over  1200  pages,  profusely  illustrated.    L3y  Subscription. 

An  American  Text-Book  qf  Physiology,    second  Edition. 

Revised,  in  Two  Volumes. 

Edited  by  AVii.i.ta.m  H.  Howell,  Ph.  D.,  M.  D.,  Professor  of  Physi- 
ology, Johns  Hopkins  University,  Baltimore,  Md.  'Pwo  royal  octavo 
volumes  of  about  600  pages  each.  Fully  illustrated.  Per  volume : 
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An  American  Text- Book  qf  Surgery.    Third  Edition. 

Edited  by  William  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.) ;  and 
J.  William  White,  M.  D.,  Ph.  D.  Handsome  octavo  volume  of  1230 
pages:  496  wood-cuts  and  37  colored  and  half-tone  ])lates.  Thoroughly 
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OF   IV.  B.  SAUNDERS   6-    CO. 


THE   NEW   STANDARD  THE  NEW  STANDARD 

The  American  Illustrated  Medical  Dictionary. 

Second  Edition,  Revised. 

For  Practitioners  and  Students.  A  Complete  Dictionary  of  the  Terms 
used  in  Medicine,  Surgery,  Dentistry,  Pharmacy,  Chemistry,  and  the 
kindred  branches,  including  much  collateral  information  of  an  encyclo- 
pedic character,  together  with  new  and  elaborate  tables  of  Arteries, 
Muscles,  Nerves,  Veins,  etc.  ;  of  Bacilli,  Bacteria,  Micrococci,  Strepto- 
cocci ;  Eponymic  Tables  of  Diseases,  Operations,  Signs  and  Symptoms, 
Stains,  Tests,  Methods  of  Treatment,  etc.,  etc.  By  W.  A.  Newman 
DoRLAND,  A.M.,  M.  D.,  Editor  of  the  "American  Pocket  Medical 
Dictionary."  Handsome  large  octavo,  nearly  800  pages,  bound  in 
full  flexible  leather.     Price,  $4.50  net;   with  thumb  index,  $5.00  net. 

Gives  a  Maximum  Amount  of   Matter   in   a    Minimum    Space    and    at  the  Lowest 

Possible  Cost. 
This  Edition  contains  all  the  Latest  Words. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  withir 
relatively  small  space.  I  find  nothing  to  criticise,  very  much  to  commend,  and  was  interested 
in  finding  some  of  the  new  words  which  are  not  in  other  recent  dictionaries." — RosWF.LL  PARK, 
Professor  of  Principles  and  Practice  of  Surgery  and  Clinical  Surgery,  Unive?-sity  of  Buffalo. 

"  I  congratulate  you  upon  giving  to  the  profession  a  dictionary  so  compact  in  its  structure, 
and  so  replete  with  information  required  by  the  busy  practitioner  and  student.  It  is  a  necessity 
as  well  as  an  informed  companion  to  every  doctor.  It  should  be  upon  the  desk  of  every  prac- 
titioner and  student  of  medicine." — JOHN  B.  MURPHY,  Professor  of  Surgery  and  Clinical 
Surgery,  Northwestern   University  Medical  School,  Chicago. 

The  American  Pocket  Medical  Dictionary.    ^*^tvt^°"' 

Edited  by  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to 
the  Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  Amer- 
ican Academy  of  Medicine.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
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The  American  Year-Book  qf  Medicine  and  Surgery. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and  investi- 
gators. Arranged  with  critical  editorial  comments,  by  eminent  Amer- 
ican specialists,  under  the  editorial  charge  of  George  M.  Gould,  M.  D. 
Year-Book  of  1901  in  two  volumes — Vol.  L  including  General  Medicine; 
Vol.  II.,  General  Surgery.  Per  volume :  Cloth,  S3. 00  net:  Half  Mo- 
rocco, $3.75   net.     Sold  by  Subscription. 

Abbott  on  Transmissible  Diseases,    second  Edition,  Revised. 

The  Hygiene  of  Transmissible  Diseases :  their  Causation,  Modes  of 
Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  ]M.  D., 
Professor  of  Hygiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo,  351  pages,  with  numerous  illustrations.     Cloth,  S2.50  net. 


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Anders'  Practice  qf  Medicine.       Fifth  Revised  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  ]\v  Jamf.s  M.  Anders, 
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Bastin's  Botany. 

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Beck  on  Fractures. 

Fractures.  By  Carl  Beck,  M.  D.,  Surgeon  to  St.  Mark's  Hospital  and 
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Beck's  Surgical  Asepsis. 

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Boisliniere's    Obstetric   Accidents,   Emergencies,   and 
Operations. 

Obstetric  Accidents,  Emergencies,  and  Operations.  By  L.  Ch.  Bois- 
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Bohm,  Davidoff,   and  Huber*s  Histology. 

A  Text-Book  of  Human  Histology.  Including  Microscopic  Technic. 
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G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of 
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of  503  pages,  with  351  beautiful  original  illustrations.     Cloth,  53-5°  net- 

Butler's  Materia  Medica,  Therapeutics,  and  Pharma- 
cology.     Third  Edition,  Revised. 

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Cerna  on  the  Newer  Remedies,     second  EdiUon,  Revised. 

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strator of  Physiology,  Medical  Department,  University  of  Texas.  Re- 
written and  greatly  enlarged.    Post-octavo,  253  pages.    Cloth,  ^i.oo  net. 


OF   W.  B.  SAUNDERS  b'    CO. 


Chapin  on  Insanity. 

A  Compendium  of  Insanity.  By  John  Vi.  Chapin,  M.  D.,  TJ..  T)., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  Honorary 
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trated.    Cloth,  ^1.25  net. 

Chapman's   Medical    Jurisprudence  and  Toxicology. 

Second  Edition,  Revised. 

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M.  D.,  Professor  of  Ins'titutes  of  Medicine  and  Medical  Jurisprudence, 
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trations and  3  full-page  plates  in  colors.     Cloth,  $1.50  net. 

Church  and  Peterson's  Nervous  and  Mental  Diseases. 

Third  Edition.  Revised  and  Enlarged. 

Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D.,  Pro- 
fessor of  Nervous  and  Mental  Diseases,  and  Head  of  the  Neurological 
Department,  Northwestern  University  Medical  School,  Chicago ;  and 
Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department, 
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Clarkson's  Histology. 

A  Text-Book  of  Histology,  Descriptive  and  Practical.  By  Arthur 
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in  the  Owen's  College,  Manchester ;  late  Demonstrator  of  Physiology 
in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages;  22  engravings 
and  174  beautifully  colored  original  illustrations.     Cloth,  $4.00  net. 

Corwin's  Physical  Diagnosis.    Third  Edition.  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur  M. 
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Medical  College,  Chicago.    219  pages,  illustrated.     Cloth,  $1.25  net. 

CrOOkshank's    Bacteriology.       Fourth  Edition.  Revised. 

A  Text-Book  of  Bacteriology.  By  Edgar  M.  Crookshank,  M.  B., 
Professor  of  Comparative  Pathology  and  Bacteriology,  King's  College, 
London.  Octavo,  700  pages,  273  engravings  and  22  original  colored 
plates.     Cloth,  $6.50  net;   Half  Morocco,  37. 50  net. 

DaCosta's    Surgery.       Third  Edition.  Revised. 

Modern  Surgery,  General  and  Operative.  By  John  Chalmers  Da 
Costa,  M.  D.,  Professor  of  Principles  of  Surgen,^  and  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia:  Surgeon  to  the  Philadelphia 
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illustrated.     Cloth,  $5.00  net;   Sheep  or  Half  Morocco,"  $6.00  net. 

Enlarged  by  over  200  Pages,  with  more  than  100  New  Illustrations. 


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Davis's  Obstetric  Nursing. 

Obstetric  and  Ciynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  V).,  Professor  of  Obstetrics  in  Jefferson  Medical  College  and  the 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist  to  the  Phila- 
delphia Hospital.  i2mo  volume  of  400  pages,  fully  illustrated. 
Crushed  Buckram,  $1.75   net. 

DeSchweinitz  on  Diseases  qf  the  Eye.   Third  Edition,  Revised. 

Diseases  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G. 
E.  DE  ScHWEixiTZ,  M.  D.,  Profcssor  of  Ophthalmology,  Jefferson  Medi- 
cal College,  Philadelphia,  etc.  Handsome  royal  octavo  volume  of  696 
pages;  256  fine  illustrations  and  2  chromo-lithographic  plates.  Cloth, 
$4.00  net;  Sheep  or  Half  Morocco,  55. 00  net. 

Dorland's  Dictionaries. 

[See  American  Illustrated  Medical  Dictionary  and  American 
Pocket-  Medical  Dictionary  on  page  3.] 

Dorland*S    Obstetrics.       second  Edition,  Revised  and  Greatly  Enlarged. 

Modern  Obstetrics.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Associate  in 
Gynecology,  Philadelphia  Polyclinic.  Octavo  volume  of  797  pages, 
with  201  illustrations.     Cloth,  S4-oo  net. 

Eichhorst's  Practice  qf   Medicine. 

.\  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  Herman  Eichhorst, 
Professor  of  Special  Pathology  and  Therapeutics  and  Director  of  the 
Medical  Clinic,  University  of  Zurich.  Translated  and  edited  by  Augus- 
tus A.  EsHNER,  M.  D.,  Professor  of  Clinical   Medicine,  Philadelphia 

Polyclinic.    Two  octavo  volumes  of  600  pages  each,  over  150  illustrations. 

Prices  per  set :   Cloth,  $6.00  net ;  Sheep  or  Half  Morocco,  57.50  net. 

Friedrich  and  Curtis  on  the  Nose,  Throat,  and  Ear. 

Rhinology,  Laryngology,  and  Otology,  and  Their  Significance  in  Gen- 
eral Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by  H. 
HoLBROOK  Curtis,  >L  D.,  Consulting  Surgeon  to  the  New  York  No.se 
and  Throat  Hospital.     Octavo,  348  pages.     Cloth,  $2.50  net. 

Frothingham's  Guide  for  the  Bacteriologist. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Frothingham, 
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Scientific  School,  Yale  L^niversity.     Illustrated.     Cloth,  75  cts.  net. 

Garrigues*  Diseases  qf  Women.    Third  Edition,  Revised. 

Diseases  of  Women.  By  Henrv  J.  Garrhjues,  A.  M.,  M.  D.,  Gyne- 
cologist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New 
York  City.  Octavo,  756  pages,  with  367  engravings  and  colored  plates. 
Cloth,  $4.50  net;  Sheep  or  Half  Morocco,  $5.50  net. 


OF   W.  B.  SAUNDERS   &-    CO. 


Gould  and  Pyle*s  Curiosities  of   Medicine. 

Anomalies  and  Curiosities  of  Medicine.  By  (;kok(;k  M.  Gould,  M.  D. 
and  Walter  L.  Pyle,  M.  J).  An  encyclopedic  collection  of  rare  and 
extraordinary  cases  and  of  the  most  striking  instances  of  abnormality  in 
all  branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive 
,  research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
volume  of  968  pages  ;  295  engravings  and  12  full-page  plates.  Popular 
Edition.      Cloth,  $3.00  net;  Sheep  or  Half  Morocco,  $4.00  net. 

Grafstrom*s  Mechano-Therapy. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gymnastics;. 
By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician,  City  Hos- 
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Cloth,  $1.00  net. 

Griffith    on    the    Baby.       second  Edition.  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Pennsylvania;  Phy- 
sician to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages; 
67  illustrations  and  5  plates.     Cloth,  $1.50  net. 

Griffith's  Weight  Chart. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania. 
25  charts  in  each  pad.     Per  pad,  50  cts.  net. 

Hart's  Diet  in  Sickness  aiid  in  Health. 

Diet  in  Sickness  and  Health.  By  Mrs.  Ernest  Hart,  formerly  Student 
of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School  of  Medi- 
cine for  Women ;  with  an  Introduction  by  Sir  Hexry  Thompson, 
F.  R.  C.  S.,  M.  D.,  London.      220  pages.     Cloth,  $1.50  net. 

Haynes*  Anatomy. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.  D.,  Professor  of 
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Heisler'S    EmbryolOgfy.       second  Edition.  Revised. 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor 
of  Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volume 
of  405  pages,  handsomely  illustrated.     Cloth,  S--5o  net. 

Hirst's    Obstetrics.       Third  Edition,  Revised  and  Enlarged. 

A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D.,  Professor 
of  Obstetrics,  University  of  Pennsyhania.  Handsome  octavo  volume 
of  873  pages;  704  illustrations,  36  of  them  in  colors.  Cloth,  $5.00  net; 
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Hyde  anb  Montgomery  on   Syphilis  anb  the  Venereal 

Diseases.       second  Edition,  Revbed  and  Greatly  Enlarged. 

Syphilis  and  ihc  \enereal  Diseases,  liy  James  Nevins  Hvuk,  M.  D., 
Professor  of  Skin  and  Venereal  Diseases,  and  Fr.\nk  H.  Montgomery, 
M.  D.,  Associate  Professor  of  Skin,  Genito-Urinary,  and  Venereal  Dis- 
eases in  Rush  Medical  College,  Chicago,  111.  Octavo,  594  ixiges, 
].rofusely  illustrated.     Cloth,  54- 00  net. 

*7^^  International  Text-Book  of  Surgery,     in  Two  volumes. 

l!v  American  and  liritish  Authors.  l^tliicd  1)\-  J.  Coleins  W'akken, 
]\i.  I).,  LL.  I).,  F.  R.  C.  S.  (Hon.  ),  Profes.sor  of  Surgery,  Harvard  Medi- 
cal School,  Boston  ;  and  A.  Peakce  Goled,  M.  S.,  F.  R.  C.  S.,  Lecturer 
on  Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex 
Hosjiital  Medical  School,  London,  Eng.  \o\.  I.  General  Surgery. — 
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"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The  clini- 
cian and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a  satis- 
faction to  the  editors  as  it  is  a  gratification  to  the   conscientious  reader." — Annals  of  Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has  very 
many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different  authors 
is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor  of  each 
writer  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the  technique 
of  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up  to  date  in 
a  ver)'  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional  parts  of  the 
body' being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which  the  reader 
may  not  learn  something  new." — Medical  Record,  New  York. 

Jackson's  Diseases  qf  the  Eye. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine.  i2mo  volume  of  535  pages,  with 
178  illustrations,  mostly  from  drawings  by  the  author.    Cloth,  $2.50  net. 

Keating's  Life  Insurance. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Ke.a.ting,  M.  D., 
Fellow  of  the  College  of  Physicians  of  Philadelphia  ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages.     With  numerous  illustrations.     Cloth,  $2.00  net. 

Keen  on  the  Surgery  qf   Typhoid  Fever. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm. 
W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  the  Principles 
of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College,  Phila- 
delphia, etc.    Octavo  volume  of  3S6  pages,  illustrated.    Cloth,  $3.00  net. 

Keen's    Operation    Blank.       second  Edition.  Revbed  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.,  Required  in  Vari- 
ous Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S. 
(Hon.),  Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia.  Price  per  pad,  blanks  for  fifty 
operations,  50  cts.  net. 


OF   W.  B.  SAUNDERS   cr'    CO. 


Kyle  on  the  Nose  and  Throat,     second  Edition. 

Diseases  of  the  Nose  and  'J'hroal.  Jiy  I).  JiKADKN  Kvlk,  M.  \).,  Clinir:al 
Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  College, 
Philadelphia.  Octavo,  646  pages;  over  150  illustrations  and  6  litho- 
graphic plates.     Cloth,  ^4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 

Laine's  Temperature  Chart. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.  D.  Size  8x131^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature, 
with  columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions,  Food, 
Remarks,  etc.  On  the  back  of  each  chart  is  given  the  Brand  treatment 
of  Typhoid  Fever.     Price,  per  pad  of  25  charts,  50  cts.  net. 

Levy,  Klemperer,  and  Eshner's  Clinical  Bacteriolo^. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Pro- 
fessor in  the  University  of  Strasburg,  and  Feijx  Klemperer,  Privat- 
docent  in  the  University  of  Strasburg.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadel- 
phia Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.50  net. 

Lockwood's  Practice  cf  Medicine.         R,4"d"'d"£jed. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lockwood, 
M.  D.,  Professor  of  Practice  in  the  Woman's  Medical  College  of  the 
New  York  Infirmary,  etc. 

Long's  Syllabus  cf  Gynecology. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  $1.00  net. 

Macdonald's  Surgical  Diagnosis  and  Treatment. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  ^L  D. 
Edin.,  F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical 
Surgery,  Hamline  University.  Handsome  octavo,  800  pages,  fully  illus- 
trated.    Cloth,  ^5.00  net;  Sheep  or  Half  Morocco,  $6.00  net. 

Mallory  and  Wright's  Pathological  Technique. 

Second  Edition,  Revised. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work  in 
Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank  B. 
Mallory,  A.  M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston  ;  and  James  H.  Wright,  A.  M., 
M.  D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston. 

McFarland's  Pathogenic  Bacteria.  ""S  b'^ytvTr' loo^jrg^. " 

Text-Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology,  ^Nledico-Chirurgical 
College  of  Philadelphia,  etc.  Octavo  volume  of  621  pages,  finely  illus- 
trated.    Cloth,  ^3.25  net. 


lo  MEDICAL   PUBLICATIONS 

Meigs  on  Feeding  in  Infancy. 

Feeding  in  Karly  inlancy.  By  Arthur  V.  Meigs,  M.  D.  Bound  in 
limp  cloth,  Mush  edges,  25  cts.  net. 

Moore's  Orthopedic  Surgery. 

A  Manual  oi  Orthoiiedic  Surgery.  By  James  E.  Moore,  M.  D.,  Pro- 
fessor of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  Uni- 
versity of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume 
of  356  pages,  handsomely  illustrated.     Cloth,  ;>2.5o  net. 

Morten's  Nurses'  Dictionary. 

Nurses'  Dictionary  of  Medical  Temis  and  Nursing  Treatment.  Con- 
taining Definitions  of  the  Principal  Medical  and  Nursing  Terms  and 
Abbreviations  ;  of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treat- 
ments, Operations,  Foods,  Appliances,  etc.  encountered  in  the  ward  or 
in  the  sick-room.  By  Honnor  Mortex,  author  of  "  How  to  Beconie 
a  Nurse,"  etc.      i6mo,  140  pages.     Cloth,  $1.00  net. 

Nancrede's  Anatomy  and  Dissection.    Fourth  Edition. 

Essentials  of  Anatomy  and  Manual  of  Practical  Dissection.  By  Charles 
B.  Nancrede,  M.  D.,  LL.  D.,  Professor  of  Surgery  and  of  Clinical  Sur- 
gery, University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with 
full-page  lithographic  plates  in  colors  and  nearly  200  illustrations.  Extra 
Cloth  (or  Oilcloth  for  dissection-room),  $2.00  net. 

Nancrede's  Principles  qf   Surgery. 

Lectures  on  the  Princi])les  of  Surgery.  By  Chas.  B.  Nan'CREDE,  M.  D., 
LL.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  LTniversity  of 
Michigan,  Ann  Arbor.    Octavo,  398  pages,  illustrated.    Cloth,  $2.50  net. 

Norris's  Syllabus  qf  Obstetrics.    Third  Edition.  Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department  of  the 
L^'niversity  of  Pennsylvania.  By  Richard  C.  Nokris,  A.  M.,  M.  D., 
Instructor  in  Obstetrics  and  Lecturer  on  Clinical  and  Operative  Obstet- 
rics, University  of  Pennsylvania.  Crown  octavo,  222  pages.  Cloth, 
interleaved  for  notes,  S2.00  net. 

Ogden  on  the  Urine. 

Clinical  Examination  of  the  Urine  and  L^rinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  y.  Bergen  Ooden,  M.  D.,  Instructor  in  Chemistry,  Harvard 
Medical  School.  Handsome  octavo,  416  pages,  with  54  illustrations 
and  a  number  of  colored  plates.     Cloth,  $3.00  net. 

Penrose's  Diseases  qf  Women.    Fourth  Edition.  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose,  M.  D., 
Ph.  D.,  formerly  Professor  of  Cjynecology  in  the  University  of  Penn- 
sylvania. Octavo  volume  of  538  pages,  handsomely  illustrated.  Cloth, 
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OF   W.  B.  SAUNDERS  &^    CO. 


Pryor — Pelvic  Inflammations. 

The  Treatment  of  Pelvic  Inflammations  through  the  Vagina.  By  W. 
R,  Pryor,  M.  D.,  Professor  of  Gynecology,  New  York  Polyclinic. 
i2mo,  248  pages,  handsomely  illustrated.     Cloth,  ^2.00  net. 

Pye's  Banda^in^. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  con- 
cerning the  Immediate  Treatment  of  Cases  of  Emergency.  By  Walter 
Pye,  F.  R.  C.  S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small 
i2rao,  over  80  illustrations.     Cloth,  flexible  covers,  75  cts.  net. 

Pyle's  Personal  Hygiene. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic 
Basis.  Edited  by  Walter  L.  Pyle,  M.  D.,  Assistant  Surgeon  to  the 
Wills  Eye  Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully 
illustrated.     Cloth,  $1.50  net. 

Raymond's  Physiology.    Revbe/SrG,eXE;.„,ed. 

A  Text-Book  of  Physiology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D., 
Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital. 

Salinger  and  Kalteyer's  Modern  Medicine. 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College ;  and  F.  J.  Kalteyer, 
M.  D.,  Assistant  Demonstrator  of  Clinical  Medicine,  Jefferson  Medical 
College.     Handsome  octavo,  801  pages,  illustrated.     Cloth,  ^4.00  net. 

Saundby's  Renal  an^  Urinary  Diseases. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.  D. 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the 
Royal  Medico-Chirurgical  Society ;  Professor  of  Medicine  in  Mason 
College,  Birmingham,  etc.  Octavo,  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  $2.50  net. 

Saunders*  Medical  Hand-Atlases. 

See  pages  1 6  and  I7« 

Saunders*  Pocket  Medical  Formulary,  sixth  Edition,  Revised. 

By  Williaini  M.  Powell,  M.  D.,  author  of  "Essentials  of  Diseases  of 
Children";  Member  of  Philadelphia  Pathological  Society.  Contain- 
ing 1844  formulae  from  the  best-known  authorities.  With  an  Appendix 
containing  Posological  Table,  Formulas  and  Doses  for  Hypodenuic 
Medication,  Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis 
and  Fetal  Head,  Obstetrical  Table,  Diet  List  for  Various  Diseases,  Mate- 
rials and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from 
Drowning,  Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive 
Fevers,  etc.,  etc.  Handsomely  bound  in  flexible  morocco,  with  side 
index,  wallet,  and  flap.     ;^2.oo  net. 

Saunders*  Question-Compends. 

See  page  15. 


MEDICAL   PUBLICATIONS 


Scudder*S    Fractures.       second  Edition.  Revised. 

The  Treatment  of  Fractures.  By  Chas.  L.  Scuddk.k,  M.  D.,  Assistant 
in  Clinical  and  Operative  Surgery,  Harvard  University  Meciical  School. 
Octavo,  460  pages,  with  nearly  600  original  illustrations.  Polished 
Buckram.  54.50  net;    Half  Morocco,  $5.50  net. 

Senn's  Genito-Urinary  Tuberculosis. 

Tuberculosis  of  the  Geniio-Urinar\-  Organs,  Male  and  Female.  By 
Nicholas  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of 
Surgery  and  of  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  320  pages,  illustrated.     Cloth,  ^3.00  net. 

Senn*s  Practical  Surgery. 

Practical  Surgery.  By  Nicholas  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Pro- 
fessor of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical 
College,  Chicago.  Handsome  octavo  volume  of  1200  pages,  profusely 
illustrated.  Cloth,  $6.00  net;  Sheep  or  Half  Morocco,  $7.00  net. 
By  Subscription. 

Senn's  Syllabus  qf  Surgery. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged  in  con- 
formity with  "An  American  Te.\t-Book  of  Surgery."  By  Nicholas 
Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College,  Chicago.     Cloth,  $1.50  net. 

Senn's    Tumors.       second  Edition,  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  Nicholas  Senn,  M.  D.  , 
Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Surgery  and  of  Clinical 
Surgery,  Rush  Medical  College,  Chicago.  Octavo  volume  of  718  pages, 
with  478  illustrations,  including  12  full-page  plates  in  colors.  Cloth, 
$5.00  net  \  Sheep  or  Half  Morocco,  $6.00  net. 

Starr's  Diets  for  Infants  and  Children. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By  Louis 
Starr,  M.  D.,  Editor  of  "An  American  Text-Book  of  the  Diseases  of 
Children."  230  blanks  (pocket-book  size),  perforated  and  neatly  bound 
in  flexible  morocco.     $1.25  net. 

Stengel's    Pathology.       Third  Edition,  Thoroughly  Revised. 

A  Text-Book  of  Pathology.  By  Alfred  Stengel,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania;  Visiting  Physician  to 
the  Pennsylvania  Hos])ital.  Handsome  octavo,  873  pages,  nearly  400 
illustrations,  many  of  them  in  colors.  Cloth,  S5.00  net ;  Sheep  or  Half 
Morocco,  $6.00  net. 

Stengel  and  White  on  the  Blood. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  Alfred 
Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Penn- 
sylvania ;  and  C.  Y.  White,  Jr.,  M.  D.,  Instructor  in  Clinical  Medicine, 
University  of  Pennsylvania.      /;/  Press. 


OF  W.  B.  SAUNDERS  &-    CO.  13 


Stevens*  Therapeutics.      Third  Edition,  Revised  and  Greatly  Enlarged. 

A  Text-Book  of  Modern  Therapeutics.  By  A.  A.  S'IKVKns,  A.  M.,  M.  I)., 
Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania. 

Stevens*  Practice  of  Medicine.     Fifth  Edition.  Revised. 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M., 
M.  D.,  Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania. Specially  intended  for  students  preparing  for  graduation  and 
hospital  examinations.  Post-octavo,  519  pages;  illustrated.  Flexible 
Leathei",  ^2.00  net. 

SteWart*S    Physiology.       Fourth  Edition.  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students  and 
Practitioners.  By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc,  Professor  of 
Physiology  in  the  Western  Reserve  University,  Cleveland,  Ohio.  Octavo 
volume  of  894  pages ;  336  illustrations  and  5  colored  plates.  Cloth, 
^3.75  net. 

Stoney*s  Materia  Medica  for  Nurses. 

Materia  Medica  for  Nurses.  By  Emily  A.  M.  Stoney,  late  Superintend- 
ent of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Boston, 
Mass.     Handsome  octavo  volume  of  306  pages.     Cloth,  $1.50  net. 

Stoney*S    Nursing.       second  Edition.  Revised. 

Practical  Points  in  Nursing.  For  Nurses  in  Private  Practice.  By  Emily 
A.  M.  Stoney,  late  Superintendent  of  the  Training-School  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass.  456  pages,  with  73  engravings 
and  8  colored  and  half-tone  plates.      Cloth,  ^1.75  net. 

Stoney*s  Surgical  Technic  for  Nurses. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  Emily  A.  M.  Stoney, 
late  Superintendent  of  the  Training-School  for  Nurses,  Carney  Hospital, 
South  Boston,  Mass.     i2mo  volume,  fully  illustrated.     Cloth,  ^1.25  net. 

Thomas's    Diet    Lists.       second  Edition,  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  Jerome  B.  Thomas,  M.  D., 
Visiting  Physician  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital.     Cloth,  $1.25  net.     Send  for  sample  sheet. 

Thornton's  Dose-Book  an^  Prescription-Writing. 

Second  Edition,  Revised  and  Enlarged. 

Dose-Book  and  Manual  of  Prescription-Writing.     By  E.  Q.  Thornton, 
.    M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia. 

Van  Valzah  aiid  Nisbet*s  Diseases  qf  the  Stomach. 

Diseases  of  the  Stomach.  By  W^illiam  W.  Van  A'alzah,  jNI.  D.,  Pro- 
fessor of  General  Medicine  and  Diseases  of  the  Digestive  Sj'Stem  and 
the  Blood,  New  York  Polyclinic ;  and  J.  Douglas  Nisbet,  M.  D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive 
System  and  the  Blood,  New  York  Polyclinic.  Octa^•o  volume  of  674 
pages,  illustrated.     Cloth,  33-5°  i^st. 


14  MEDICAL   PUBLICATIONS. 

Vecki'S    Sexual    Impotence.        second   Edition.  Revised. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor  G. 
Vkcki,  M.  D.  From  the  second  Cierman  edition,  revised  and  enlarged. 
Demi-octavo,  291   pages.     Cloth,  $2.00  net. 

VierOrdt*S    Medical     Diagnosis.       Fourth  Edition.  Revised. 

Medical  Diagnosis.  By  I>k.  Uswald  Vierordt,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth 
enlarged  German  edition,  with  the  author's  permission,  by  Francis  H. 
SruART,  A.M.,  M.  D.  Handsome  octavo  volume,  603  pages;  194 
wood-cuts,  many  of  them  in  colors.  Cloth,  34.00  net;  Sheep  or  Half 
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Watson's  Handbook  for  Nurses. 

A  Handbook  for  Nurses.  By  J.  K.  AVatson,  M-  D.  Edin.  American 
Edition,  under  supervision  of  A.  A.  Stevens,  A.M.,  M.  D.,  Lecturer 
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Warren's  Surgical  Pathology,     second  Edition. 

Surgical  Pathology  and  I'herapeutics.  By  Jf)HN  Collins  Warren, 
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Medical  School.  Handsome  octavo,  873  pages;  136  relief  and  litho- 
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1.  Essentials  of  Physiology.     By  Sidney  Budgett,  M.  D.     A  N'cw  Work. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.D.     Seventh  edition,  revised,  with 

an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By   Charles    B.    Nancrede,    M.  D.     Sixth   edition,  thor- 

ouglily  revised  and  enlarged. 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.     By  Lawre.nce  Wolff, 

M.  D.      Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  JNI.  D.    Fourth  edition,  revised 

and  enlarged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.     By  F.  J.  Kalteyer,  M.  D.     In 

prepaj-ation. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Writing.    By  Henry 

Morris,  M.  \).     Fifth  edition,  revised. 

8.  9.    Essentials  of  Practice  of  Medicine.     By  Henry  Morris,  M.  D.     An  Appendix 

on  Urine  Examination.  By  Lawrence  Wolff,  M.  D.  Third  edition,  enlarged 
by  some  300  Essential  Formulas,  selected  from  eminent  authorities,  by  Wm.  M. 
Powell,  M.  D.      (Double  number,  ^1.50  net.) 

10.  Essentials  of  Gynecology.     By  Edwin  B.  Cragin,  M.  D.     Fifth  edition,  revised. 

11.  Essentials  of  Diseases  of  the  Skin.     By  Henry  W.  Stelwagon,  M.  D.     Fourth 

edition,  revised  and  enlarged. 

12.  Essentials  of  Minor  Surgery,  Bandaging,  eind  Venereal    Diseases.     By  Edward 

Martin,  M.  D.     Second  edition,  revised   and  enlarged. 

13.  Essentials    of   Legal    Medicine,   Toxicology,   and   Hygiene.     This   volume   is   at 

present  out  of  print. 

14.  Essentials  of  Diseases  of  the  Eye.     By  Edward  Jackson,  M.  D.     Third  edition, 

revised  and  enlarged. 

15.  Essentials  of  Diseases  of  Children.    By  William  M.  Powell,  M.  D.    Third  edition. 

16.  Essentials    of    Examination    of    Urine.     By   Lawrence   Wolff,   AL  D.      Colored 

'•  VoGEL  Scale."     (75  cents  net.) 

17.  Essentials  of  Diagnosis.     By  S.   Solis-Cohen,   M.  D.,  and  A.   A.  Eshner,  M.  D. 

Second  edition,  thoroughly  revised. 

18.  Essentials    of    Practice    of    Pheumiacy.     By  Lucius    E.    Sayre.     Second   edition, 

revised  and  enlarged. 

19.  Essentials  of  Diseases  of  the  Nose  and  Throat.     By  E.  B.  Gleason,  M.  D.     Third 

edition,  revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  V.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Diseases  and  Insanity.     By  John  C.  Shaw,  M.  D.     Third 

edition,  revised. 

22.  Essentials  of    Medical    Physics.     By  Fred  J.   Brockway,  ^L  D.     Second  edition, 

revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart,  AL  D.,  and  Edward 

S.  Lawrance,  M.  D. 

24.  Essentials  of  Diseases  of  the  Ezu:.     By  E.  B.   Gleason,   M.  D.     Second   edition, 

revised  and  greatly  enlarged. 

25.  Essentials  of  Histology.     By  Louis  Lkroy,  M.  D.     With  73  original  illustrations. 


Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 


Saunders'   Medical    Hand-Atlases. 


VOLUMES    NOW    READY. 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
Dia£>nosis. 

By  Dr.,  Chr.  jAKor.,  of  Erlangen.  Edited  by  Augustus  A.  Eshnf.r, 
^L  I).,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With 
179  colored  figures  on  6S  plates,  64  text-illustrations,  259  pages  of  text. 
Cloth,  53.00  net. 

Atlas  of  Legal  Medicine. 

By  Dr.  E.  R.  von  Hofmaxn,  of  Vienna.  Edited  by  Frederick. 
Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of 
Physicians  and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates  and   193  beautiful  half-tone  illustrations.      Cloth,  53.50  net. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx. 

By  Dr.  L.  Grunwald,  of  Munich.  Edited  by  Charles  P.  Grayson, 
M.  D.,  Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of 
the  University  of  Pennsylvania.  With  107  colored  figures  on  44  plates, 
25  text-illustrations,  and  103  pages  of  text.     Cloth,  $2.50  net. 

Atlas  and  Epitome  of  Operative  Surgery. 

By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited  by  J.  Chalmers 
DaCosta,  M.  D.,  Professor  of  Principles  of  Surgery  and  Clinical  Sur- 
gery, Jefferson  Medical  College,  Philadelphia.  With  24  colored  plates, 
217  text-illustrations,  and  395  pages  of  text.     Cloth,  S3-oo  net. 

Atlas   and   Epitome   of    Syphilis    and  the   Venereal 
Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton 
Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  71  colored 
plates,  16  illustrations,  and  122  pages  of  text.     Cloth,  S3. 50  net. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr.  O.  Haab,  of  Zurich.  ICdited  by  G.  E.  de  Schweinitz,  M.  I)., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia. 
With  76  colored  illustrations  on  40  plates  and  228  pages  of  text. 
Cloth,  $3. 00  net. 

Atlas  and  Epitome  of  Skin  Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  A'ienna.  P^dited  by  Henry  W.  Stel- 
WAGON,  M.  D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical 
College,  Philadelphia.  With  63  colored  plates,  39  half-tone  illustra- 
tions, and  200  pages  of  text.     Cloth,  S3. 50  net. 

Atlas  and  Epitome  of  Special  Patholog-ical  Histology. 

By  Dr.  H.  Durck,  of  Munich.  Edited  by  Ludwig  Hektoen  M.  D., 
Professor  of  Pathology,  Rush  iMedical  College,  Chicago.  In  Two  Parts. 
Part  I.  Ready,  including  Circulatory,  Respiratory,  and  Gastro-intestinal 
Tract,  120  colored  figures  on  62  plates,  158  pages  of  text.  Part  II. 
Ready  Shortly.     Price  of  Part  I.,  S3. 00  net. 

16 


Saunders'  Medical   Hand-Atlases. 


VOLUMES    JUST    ISSUED. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

J5y  Dr.  Ed.  (tOLE1!IEWski,  of  iJerlin.  'I'ranslated  and  edited  with  addi- 
tions by  Pearce  Bailey,' M.  D.,  Attending  Physician  to  the  Department 
of  Corrections  and  to  the  Almshouse  and  Incurable  Hospitals,  New 
York.  With  40  colored  plates,  143  text-illustrations,  and  600  pages 
of  text.     Cloth,  $4.00  net. 

Atlas  and  Epitome  of  Gynecology. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  From  the  Second  Revised  Ger- 
man Edition.  Edited  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gyne- 
cologist to  the  Methodist  Episcopal  and  the  Philadelphia  Hospitals; 
Surgeon-in-Charge  of  Preston  Retreat,  Philadelphia.  With  90  colored 
plates,  65  text-illustrations,  and  308  pages  of  text.     Cloth,  I3.50  net. 

Atlas   and  Epitome  of  the  Nervous  System  and  its 
Diseases. 

By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Re- 
vised and  Enlarged  German  Edition.  Edited  by  Edward  D.  Fisher, 
M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  83  plates  and  a 
copious  text.     Cloth,  ^3.50  net. 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Fifth  Revised  and 
Enlarged  German  Edition.  Edited  by  J.  Clifton  Edgar,  M.  D., 
Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School.      With   126  colored  illustrations.      Cloth,  $2.00  net. 

Atlas    and     Epitome    of     Obstetric     Diagnosis     and 
Treatment. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  and  En- 
larged German  Edition.  Edited  by  J.  Clifton  Edgar,  M.  D.,  Professor 
of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School. 
72  colored  plates,  text-illustrations,  and  copious  text.      Cloth,  53-°°  ^^t. 

Atlas   and   Epitome   of   Ophthalmoscopy   and    Oph- 
thalmoscopic   Diagnosis. 

By  Dr.  O.  Haab,  of  Zurich.  Fi'om  the  Third  Revised  and  Enlarged 
German  Edition.  Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Profe.ssor 
of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  152 
colored  figures  and  82  pages  of  text.      Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Bacteriology. 

Including  a  Text-Book  of  Special  Bacteriologic  Diagnosis.  By  Prof. 
Dr.  K.  B.  Lehmann  and  Dr.  R.  O.  Neumann,  of  Wurzburg.  From  the 
Second  Revised  German  Edition.  Edited  bv  George  H.  Weaver,  M.  D., 
Assistant  Professor  of  Pathology  and  Bacteriologv,  Rush  Medical  College, 
Chicago.  Two  volumes  with  over  600  colored  lithographic  figures, 
numerous  text-illustrations,  and  500  pages  of  text. 


ADDITIONAL  VOLUMES   IN   PREPARATION. 

17 


NOTHNAGEL'S   ENCYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 

Edited  by  ALFRED    STENGEL.  M.  D. 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania ;  Visiting 
Physician  to  the  Pennsylvania  Hospital 

IT  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal 
Medicine  ;  and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Ency- 
clopedia of  Special  Pathology  and  Therapeutics"  is  conceded  by  scholars  to 
be  without  question  the  best  System  of  Medicine  in  existence.  So  necessary 
is  this  book  in  the  study  of  Internal  Medicine  that  it  comes  largely  to  this  country 
in  the  original  German.  In  view  of  these  facts,  Messrs.  W.  B.  Saunders  &  Com- 
pany have  arranged  with  the  publishers  to  issue  at  once  an  authorized  edition 
of  this  great  encyclopedia  of  medicine  in  English. 

For  the  present  a  set  of  some  ten  or  twelve  volumes,  representing  tiie  most 
practical  part  of  this  encyclopedia,  and  selected  with  especial  thought  of  the  needs 
of  the  practical  physician,  will  be  published.  The  volumes  will  contain  the  real 
essence  of  the  entire  work,  and  the  purchaser  will  therefore  obtain  at  less  than 
half  the  cost  the  cream  of  the  original.  Later  the  special  and  more  strictly 
scientific  volumes  will   be  offered   from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  lioth 
English  and  German,  and  each  volume  will  be  edited  by  a  prominent  specialist 
on  the  subject  to  which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to 
•date,  and  the  American  edition  will  be  more  than  a  mere  translation  of  the  Ger- 
man ;  for,  in  addition  to  the  matter  contained  in  the  original,  it  will  represent  the 
very  latest  views  of  the  leading  American  specialists  in  the  various  departments 
of  Internal  Medicine.  The  whole  Sy.stem  will  be  under  the  editorial  super- 
vision of  Dr.  Alfred  Stengel,  who  will  select  the  subjects  for  the  American  edition, 
and  will  choose  the  editors  of  the  different  volumes.     . 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended 
over  a  number  of  years,  but  five  or  six  volumes  will  be  issued  during  the  coming 
year,  and  the  remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume 
will  be  revised  to  the  date  of  its  publicatfon  by  the  American  editor.  This  will 
obviate  the  objection  that  has  heretofore  existed  to  systems  published  in  a  number 
of  volumes,  since  the  subscriber  will  receive  the  completed  work  while  the  earlier 
volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been 
to  compel  physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases 
to  be  undesirable.  Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be 
given  the  opportunity  of  subscribing  for  the  entire  System  at  one  time ;  but  an\- 
single  volume  or  any  number  of  volumes  may  be  obtained  by  those  who  do  not 
desire  the  complete  series.  This  latter  method,  while  not  so  profitable  to  the  pub- 
lisher, offers  to  the  purchaser  many  advantages  which  will  be  appreciated  by  those 
who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

This  American  edition  of  Notlinagel's  Encyclopedia  will,  without  question, 
form  the  greatest  System  of  Medicine  ever  produced,  and  the  pulilishers  feel  con- 
fident that  it  will  meet  with  general  favor  in  the  medical  profession. 


NOTHNAGEL^S  ENCYCLOPEDIA 

VOLUMES  JUST  ISSUED  AND  IN  PRESS 


VOLUME  I 
Editor,  William  Osier,  M.  D.,  F.  R.  C.  P. 

Professor  of  Medicine  in  Johns  Hopkins 
Uniiiersiiy 

CONTENTS 
Typhoid  Fever.     By  Dr.  H.  Curschmann, 
uf  Leipsic.     Typhus  Fever.     By  Dr.  H. 

Curschmann,  of  Leipsic. 

Handsome  octavo  volume  of  about  600  pages. 
Just  Issjifd 


VOLUME  II 

Editor,  Sir  J.  W.  Moore,  B.  A.,  M.D., 
F.R.C.P.I.,  of  Dublin 

Professor  of  Practice  of  Medicine,  Royal  College 
of  Surgeons  in  Ireland 

CONTENTS 

Erysipelas  and  Erysipeloid.  By  Dr.  H.Len- 
HARTZ,  of  Hamburg.  Cholera  Asiatica  and 
Cholera  Nostras.  By  Dr.  K.  von  Lieeer- 
meister,  ot  Tiibingen.  "Whoooing  Cough 
and  Hay  Fever.  By  Dr.  G.  Sticker,  of 
Giessen.  Varicella.  By  Dr.  Tn.  von  JiJR- 
GENSEN,  of  Tiibingen.  Variola  (including 
Vaccination).  Ey  Dr.  H.  Immermann,  of 
Basle. 

Haudsome  octavo  volume  of  over  700  pages. 
Just  Issued 


VOLUME   VII 
Editor,  John  H.  Musser,  M.  D. 

Professor  of  Clinical  Medicine,  University  of 
Pennsylva  n  ia 

CONTENTS 

Diseases  of  the  Bronchi.  By  Dk-  F.  A.  I  I'-i-f- 
MANN,  of  Leip.sic.  Diseases  of  the  Pleura. 
By  Dr.  Rosenbach,  of  Berlin.  Pneumonia. 
By  Dr.  E.  Aufrecht,  of  Magdeburc,'. 


VOLUME  VIII 
Editor,  Charles  G.  Stockton,  M.  D. 

Professor  of  Medicitie,  University  of  Buffalo 
CONTENTS 

Diseases  of  the  Stomach.    By  Dr.  F.  Riegel, 

of  Giessen. 


VOLUME  EX 
Editor,  Frederick  A.  Packard,  M.  D. 

Physician  to  the  Pennsylvania  Hospital  ajzd  to  the 
Children' s  Hospital,  Philadelphia 

CONTENTS 

Diseases  of  the  Liver.   By  Drs.  H.  Quincke 
and  G.  Hoppe-Seyler,  of  Kiel. 


VOLUME  m 
Editor,  William  P.  Northrup,  M.  D. 

Professor  of  Pediatrics,  University  and  Bellevue 
Medical  College 

CONTENTS 

Measles.  By  Dr.  Th.  von  Jurgensen,  of 
Tiibingen.  Scarlet  Fever.  By  the  same 
author.     Rotheln.    By  the  same  author. 


VOLUME   X 
Editor,  Reginald  H.  Fitz,  A.M.,  M.  D. 

Hersey  Professor  of  the  Theory  and  Practice 
of  Physic,  Harvard  University 

CONTENTS 

Diseases  of  the  Pancreas.     By  Dr.  L.  Oser, 
of  ^'ienna.     Diseases  of  the  Suprarenals. 

iJv  Dr.  E.  Neusser,  of  Vienna. 


VOLUME  VI 
Editor,  Alfred  Stengel,  M.D. 

Professor  of  Clinical  Medicine,  University  of 
Pennsylva7iia 

CONTENTS 

Anemia.  By  Dr.  P.  Ehrlich,  of  Frankfort- 
on-the-Main,  and  Dr.  A.  Lazarus,  of  Char- 
lottenburg.  Chlorosis.  By  Dr.  K.  von 
NOORDEN,  of  Frankfort-on-the-Main.  Dis- 
eases of  the  Spleen  and  Hemorrhagic 
Diathesis.    By  Dr.  M.  Litten,  of  Berlin. 


VOLUMES  rV,  V,  and  XI 
Editors  announced  later 

Vol.  IV.— Influenza  and  Dengue.  By  Dr.  O. 

Leichtenstern,  of  Cologne.  MalarialDis- 

eases.    By  Dr.  J-  Mannaberg,  oi  \'ienna. 
Vol.  \  . — Tuberculosis  and  Acute  General 

Miliary  Tuberculosis.    By  Dr.  G.  C'  'RNEt, 

of  Berlin. 

Vol.  XI. — Diseases  of  the  Intestines  and 
Peritoneum.  By  Dr.  H.  Xothnagel, 
of  Vienna. 


19 


CLASSIFIED   LIST 

OF   THE 

MEDICAL    PUBLICATIONS 


or 


W.  B.  SAUNDERS  6?  COMPANY 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Bbhm,  Davidofif,  and  Huber — A  Text- 
Book  of  Histology 

ClarkBon — A  Text-Book  of  Histology,  .    . 

Haynes— A  Manual  of  Anatomy 

Heisler— A  Text-Book  of  Embryology,  .    . 

Leroy — Essentials  of  Histology 

Nancrede — lisscntials  of  Anatomy 

Nancrede — ]-2ssentials  of  Anatomy  and 
Manual  of  Practical  Dissection 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology 

Frothingliain — Laboratory  Guide,  .... 

Gorliam  — Laboratory  Course  in  Bacteri- 
olouy 

Leliinann  and  Neumann — Atlas  of  Bacte- 
riology  

Levy  and  Klemperer's  Clinical  Bactcr  - 
ology 

Malloryand  Wright— Pathological  Tech- 
nique  

McFarland — Pathogenic  Bacteria 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart, 

Hart — Diet  in  -Sickness  and  in  Health,  .    . 

Keen— Operation  Blank 

Laine — Temperature  Chart 

Meigs — Feeding  in  Early  Infancy 

Starr— D:ets  for  Infants' and  Children,  .  . 
Thomas — Diet-Lists 

CHEMISTRY  AND  PHYSICS. 
Brockway— Essentials  of  Medical  Physics, 
Wolff — Essentials  of  Medical  Chemistry,  . 

CHILDREN. 
An  American  Text-Book  of  Diseases  of 

Ciiildrcn 

Griffith— Care  of  the  Baby 

Griffith- Infant's  Weight  Chart 

Meigs — Feeding  in  Early  Infancy,  .... 
Powell — Essentials  of  Diseases  of  Children, 
Starr— Diets  for  Infants  and  Children,  .    . 

DIAGNOSIS. 
Cohen  and  Eshner— Essentials  of  Diag- 
nosis,     

Corwln — Physical  Diagnosis 

Vlerordt — Medical  Diagnosis 

DICTIONARIES. 
The  American  Illustrated  Medical  Dic- 
tionary  

The  American  Pocket  Medical  Dictionary, 
Morten — Nurses'  Dictionary 


17 


13 


15 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text-Book  of  Diseases  of 

the  l-^se.  Ear,  Nose,  und  Throat I 

De  Schweinitz— Diseases  of  the  Eye,  .  .  6 
Friedrich  and  Curtis — khinology,  Laryn- 

Liology  and  Otology 6 

Gleason — ]£s.seiuials  of  Diseases  of  tlie  Ear,  15 

Gleason — Ess.  of  Dis.  of  Nose  and  Throat,  15 

Gradle — Ear,  Nose,  and  Throat 22 

Griinwald   and    Grayson— Atlas  of  Dis- 
eases of  tiic  Larynx 16 

Haab  and  De  Schweinitz — Atlas  of  Exter- 
nal Di'^ea.es  of  tli.'  Ey 16 

Haab  and  De  Schweinitz— Atlas  of  Oph- 
thalmoscopy,       17 

Jackson — Manual  of  Diseases  of  the  Eye,  8 

Jackson — Essentials   of   Diseases  of   Eye,  15 

Kyle — Diseases  of  the  Nose  and  Throat,  .  9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito-L'ri- 

nary  and  Skin  Diseases 2 

Hyde  and  Montgomery — Syphilis  and  the 

Venereal  Diseases 8 

Martin — Essentials     of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,  ...  15 
Mracek  and  Bangs — Atlas  of  Syphilis  and 

the  Venereal  Diseases 16 

Saundby — Renal  and  Urinary  Diseases,  .  .  11 
Senn — Genito-Urinary  Tuberculosis,  ...  12 
■Vecki — Sexual  Impotence 14 

GYNECOLOGY. 

American  Text-Book  of  Gynecology,   .    .  2 

Cragin — Essentials  of  Gynecology 15 

Garrigues — Diseases  of  Women 6 

Long — Syllabus  of  Gynecology 9 

Penrose — Diseases  of  Women 10 

Pryor — Pelvic  Inflammations II 

S3haeffer  &  Norris — Atlas  of  Gynecology,  17 

HYGIENE. 
Abbott — Hygiene  of  Transmissible  Diseases    3 

Bergey — Principles  of  Hygiene, 22 

Pyle — Personal   Hygiene 11 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

American  Text-Book  of  Therapeutics,  .  .  i 
Butler — Text-Book    of    Materia    Medica, 

Therapeutics,  and  Pharmacology,    ...  4 

Morris — Ess.  of  M.  M.  and  Therapeutics,  15 

Saunders'  Pocket  Medical  F'ormulary,  .    .  11 

Sayre — Essendals  of  Pharmacy, 15 

Sollmann — Text- Book  of  Pharmacology,  .  22 

Stevens — Manual  of  Therapeutics,    ...  13 

Stoney — Materia  Medica  for  Nurses,   .    .  13 

Thornton — Prescription-Writing 13 


20 


MEDICAL  PUBLICATIONS  OF  IV.  B.  SAUNDERS  6-  CO.    21 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman — Medical  Jurisprudence  and 
Toxicology, 5 

Golebiewskl  and  Bailey — Atlas  of  Dis- 
eases Caused  by  Accidents 17 

Hofmann  and  Peterson— Atlas  of  Legal 
Medicine 16 

NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Brower — Manual  of  Insanity 22 

Chapin — Compendium  of  Insanity,    ...  5 
Church  andPeterson — Nervous  and  Men- 
tal Diseases 5 

Jakob  &  Fisher —Atlas  of  Nervous  System,  17 
Shaw — Essentials  of  Nervous  Diseases  and 

Insanity 15 

NURSING. 

Davis — Obstetric  and  Gynecologic  Nursing,  6 

Griffith— The  Care  of  the  Baby 7 

Hart — Diet  in  Sickness  and  in  Health,   .    .  7 

Meigs — Feeding  in  Early  Infancy 10 

Morten — Nurses'  Dictionary, 10 

Stoney — Materia  Medica  for  Nurses,      .    .  13 

Stoney — Practical  Points  in  Nursing,  ...  13 

Stoney — Surgical  Technic  for  Nurses,    .    .  13 

Watson — Handbook  for  Nurses 14 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics 
Ashton — Essentials  of  Obstetrics, 
Boislini6re — Obstetric  Accidents, 
Borland— Modern  Obstetrics,  . 
Hirst — Text-Book  of  Obstetrics, 
Norris — Syllabus  of  Obstetrics,   . 
Schaeffer  and  Edgar — Atlas  of  Obstetri- 
cal Diagnosis  and  Treatment 17 

PATHOLOGY. 
An  American  Text-Book  of  Pathology,    .     2 
Durck  and  Hektoen — Atlas  of  Pathologic 

Histology,      16 

Kalteyer — Essentials  of  Pathology,    ...    15 
Mallory  and  Wright — Pathological  Tech- 
nique  9 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors 12 

Stengel — Text-Book  of  Pathology,    ...    12 
Warren — Surgical  Pathology  and  Thera- 
peutics  14 

PHYSIOLOGY. 

An  American  Text-Book  of  Physiology,  2 
Budgett — Essentials  of  Physiology,  ...  15 
Raymond — Text-Book  of  Physiology,  .  .  11 
Stewart—  Manual  of  Physiology,    ....    13 

PRACTICE  OF  MEDIQNE. 
An  American  Year-Book  of  Medicine  and 

Surgery,      3 

Anders — Practice  of    Medicine, 4 

Eichhorst— Practice  of  Medicine 6 

Lockwood — Manual    of    the    Practice    of 

Medicine 9 

Morris — Ess.  of  Practice  of  Medicine,  .    .    15 
Salinger  and  Kalteyer — Modern   Medi- 
cine,     II 

Stevens — Manual  of  Practice  of  Medicine,    13 


SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary nnd  Skin  Disease;-,, 2 

Hyde  and  Montgomery — Syphilis  and  the 
Venerea)   Dise-ases, 8 

Martin —  lissentials  of  Minor  Surgery, 
]5andnging,  and  Venereal  Diseases,     .    .    15 

Mracek  and  Stelwagon — Atlas  of  Diseases 
of  the  Skm 16 

Stelwagon — Essentials  of  Diseases  of  the 
Skin 15 

SURGERY. 

An  American  Text-Book  of  Surgery,  .  .  2 
An  American  Year-Book  of  Medicine  and 

Surgery 3 

Beck — Fractures 4 

Beck — Manual  of  Surgical  Asepsis,    ...  4 

Da  COBta — Manual  of  Surgery 5 

International  Text-Book  of  Surgery,  .    .  8 

Keen — Operation  Blank 8 

Keen — The    Surgical    Complications   and 

Sequels  of  Typhoid  Fever 8 

Macdonald — Surgical  Diagnosis  and  Treat- 
ment   9 

Martin —  Essentials    of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,      .    .  15 

Martin— Essentials  of  Surgery 15 

Moore — Orthopedic  Surgery 10 

Nancrede — Principles  of  Surgery,  ....  10 

Pye — Bandaging  and  Surgical  Dressing,     .  11 

Scudder — Treatment  of  Fractures,     ...  12 

Senn — Genito-Urinary  Tuberculosis,  ...  12 

Senn — Practical  Surgery 12 

Senn — Syllabus  of  Surgery 12 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors 12 

Warren — Surgical  Pathology  and  Thera- 
peutics   14 

Zuckerkandl  and    Da    Costa — Atlas    of 

Operative  Surgery, 16 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical  Examination  of  the  Urine,    10 
Saundtoy — Renal  and  Urinary  Diseases,    .    11 
Wolff —  Handbook     of      Urine-Examina- 
tion,      22 

Wolff —  Essentials      of     Examination     of 
Urine 15 

MISCELLANEOUS. 

Bastin^ — Laboratory  Exercises  in  Botany,  .      4 
Golebiewski  and  Bailey — Atlas  of  Dis- 
eases Caused  by  Accidents 17 

Gould  and  Pyle — Anomalies  and  Curiosi- 
ties of  Medicine 7 

Grafstrom — Massage, 7 

Keating — How  to  Examine  for  Life  Insur- 
ance      s 

Saunders'  Medical  Hand-Atlases,  .  .  16,17 
Saunders'  Pocket  Medical  Formulary,  .  .  11 
Saunderb'  Question-Compends,  .  .  .  14.15 
Stewart    and    Lawrence — Essentials    of 

Medical  Electricity 15 

Thornton — Dose-Book    and    Manual    of 

Prescription-Writing 13 

Van  Valzah  and  Nisbet — Diseases  of  the 
Stomach, 13 


THE  LATEST  BOOKS. 


Bergey's  Principles  of   Hygiene. 

The  Principles  of  Ilxi^iene:  A  Practical  Manual  for  Students, 
Physicians,  and  Health  Officers.  Hy  D.  H.  Bergev,  A.  M.,  M.  D.. 
First  Assistant,  Laboratorj-  of  H)-gicne,  University  of  Pennsyl- 
vania.     Handsome  octavo  volume  of  about  500  pages,  illustrated. 

Brower's  Manual  of   Insanity. 

A  Practical  Manual  of  Insanity.  By  Daniel  R.  Brower,  M.  D., 
Professor  of  Nervous  and  Mental  Diseases,  Rush  Medical  College, 
Chicago.      i2mo  volume  of  425  pages,  illustrated. 

Gorham's  Bacteriology. 

A  Laboratory  Course  in  Bacteriology.  By  F.  P.  Gorham,  M.  A., 
Assistant  Professor  in  Biology,  Brown  University.  i2mo  volume 
of  about  160  pages,  handsomely  illustrated. 

.Gradle  on  the  Nose,  Throat,  and  Ear. 

Diseases  -of  the  Nose,  Throat,  and  ICar.  By  Henry  Gradle, 
M.  D.,  Professor  of  Ophthalmology  and  Otology,  Northwestern 
University  Medical  School,  Chicago.  Handsome  octavo  volume 
of  800  pages,  profusely  illustrated. 

Sollmann's  Pharmacology. 

A  Text-Book  of  Pharmacology.  By  Torald  Sollmann,  M.  D., 
Lecturer  on  Pharmacolog}',  Western  Reserve  University,  Cleve- 
land, Ohio.      Royal  octavo  volume  of  about  700  pages. 

Wolfs  Examination  of   Urine. 

A  Handbook  of  Physiologic  Chemistry  and  Urine  Examination. 
By  Chas.  G.  L.  Wolf,  ?kI.D.,  Instructor  in  Physiologic  Chemistry, 
Cornell  University  Medical  College.  i2mo  volume  of  about  160 
pages. 


\^ad^t.    ^  [^^\^^^^ 


